^^^v^-:^u'w^ix«?i^'?j'^^^(mmii)m'm'mir'm 


Columbia  (Bnit)em'tp%<a^3  o 

College  of  ^i)pssictang  anti  ^urgeong 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/principlespracti1908dudl 


Glandulae    lympUaticae   lumbale 
Arteria    ovarica 


A.  Kaemorrhoidalis    superior 

Aorta    abdominalis 
Truficus   Sympathicus 
V.  ovarica 
A.  ovarica 
A-iiiaca  communis 
iliaca  tommunis 
.Jemtocruralis 
'*]iaca  int. 

i'ihaca^ext 
V. iliaca  ext. 


'-V.  epigastrica 

profunda  Ligamtrjtu 

A         •  ■  Tees 

"A. epigastrica 

profunda 


Plica    vesicalis    traasvcri 


SI       '         ,        '.rossa  para- 
y^nphys.s    OS-         v^sicalis 

SlOrn       Pubis  s'r,f^r;nr 


^  ,      A.ve5Tcalis 

Plexus  veno5us\        superior 
utero-valmalis-     \    . 

'A  vesico- 

Plexus  venosus 
vesico-vaginalis 


A  STUDY   FROM   NUMEROUS  DISSECTIONS  AND  PLATES. 


THE 


PRINCIPLES  AND  PRACTICE 


GYNECOLOGY 


STUDENTS  AND  PRACTITIONERS. 


BY 

E.  C.  DUDLEY,  A.  M.,  M.  D., 

EX-PRESIDENT   OF   THE   AMERICAN    GYNECOLOGICAL  SOCIETY  ;    PROFESSOR    OF  GYNECOLOGY,  NORTH- 
WESTERN   UNIVERSITY    MEDICAL   SCHOOL  ;    GYNECOLOGIST    TO    ST.    LUKE'S    AND    WESLEY 
HOSPITALS,     CHICAGO ;     EX-PR1£SIDENT     OF     THE    CHICAGO    GYNECOLOGICAL 
SOCIETY  ;     ONE     OF     THE     FOUNDERS    OF    CONGRES    PERIODIQUE 
INTERNATIONAL    DE   GYN^COLOGIE   ET   d'OBSTETRIQUE  ; 
FELLOW     OF      THE      ROYAL      SOCIETY      OF 
MEDICINE,    ENGLAND. 


FIFTH  EDITION,  REVISED  AND  ENLARGED. 


WITH    431     ILLUSTRATIONS    AND    20     FULL- PAGE    PLATES    IN 
COLORS    AND    MONOCHROME. 


\ 


t) 


\ 


9^^ 


>, 


\J 


I.EA     &     FEBIGER, 

PHILADELPHIA     AND     NEW     YORK 
1908 


Kiitered  according  to  Act  of  Congress,  in  the  year  1908,  by 

LEA  &    FEBIGER, 

In  the  Office  of  the  Librarian  of  Congress.     All  riglits  reserved. 


WESTGOTT    &    THOMSON.  WILLIAM    J.     DORNAN, 

ELECTROTYPERS,    PHILAOA.  PRINTER,   PHILADA. 


TO 

THOMAS    ADDIS    EMMET 

This  Book  is  Gratefully 
and  Affectionately  Dedicated. 


"This  subject  of  man's  body  is  of  all  other  things  in 
nature  most  susceptible  of  remedy;  but  then  that  remedy 
is  most  susceptible  of  error.  For  the  same  subiility  of  the 
subject  doth  cause  large  possibility  and  easy  failing;  and 
therefore  the  inquiry  ought  to  be  the  more  exact." 

Francis  Bacon,  in  the  Second  Book  of  the  Proficience  and 
Advancement  of  Learning. 


PREFACE  TO  THE  FIFTH   EDITION. 


In  accordance  with  the  plan  of  the  book  as  set  forth  in  the  prefaces 
to  former  editions  I  have  divided  the  subjects,  not  in  the  usual  man- 
ner of  grouping  in  each  part  all  the  diverse  diseases  of  some  special 
organ,  but  so  far  as  practicable  have  arranged  them  in  pathological 
and  etiological  sequence.  For  example,  infections  and  inflammations 
are  brought  together  so  that  vulvovaginitis,  metritis,  salpingitis,  ova- 
ritis, peritonitis,  and  cellulitis  may  be  studied  in  the  combined  forms 
\vhich  frequently  they  assume.  In  like  manner,  tumors  are  treated 
in  another  part,  traumatisms  in  another,  and  displacements  in  another. 
Under  this  plan  the  student,  it  is  thought,  will  have  constantly  before 
him  the  physiological  and  pathological  unity  of  the  reproductive 
system ;  on  the  other  hand,  if  he  considered  all  the  diseases  of  each 
organ  in  a  part  by  itself,  he  would  find  tumors,  traumatisms,  displace- 
ments, and  other  anomalies  thrown  in  between  the  infections  of  that 
organ  and  causal  or  resultant  infections  in  other  parts  of  the  pelvis, 
and  thus  might  lose  sight  of  the  significance  of  morbid  processes  and 
the  relations  of  those  processes  to  one  another. 

I  have  endeavored  to  make  a  thoroughgoing  revision  of  the  text, 
which  should  include  the  recent  advances  in  Gynecology,  and  in  so 
doing  have  condensed,  rewritten,  and  rearranged  many  parts,  and  in 
this  way  have  found  space  for  considerable  new  matter  without  mate- 
rially enlarging  the  volume.  The  following  chapters  have  been  sub- 
jected to  special  changes  and  practical  additions  :  Chapter  XXIII., 
Treatment  of  Salpingitis,  Ovaritis,  and  Pelvic  Peritonitis ;  Chapter 
XXVII.,  Treatment  of  Myoma  Uteri ;  Chapter  XXYIIL,  Treat- 
ment of  Carcinoma  Uteri ;  Chapter  XLV.,  Treatment  of  Descent  of 
the  Uterus ;  and  Chapter  XLYIL,  Treatment  of  Retroversion  and 
Retroflexion.  I  have  added  two  new  chapters,  an  introductory  chap- 
ter, and  Chapter  LV.,  on  Incontinence  of  Urine  in  Women. 

All  illustrations  and  plates  have  been  reproduced  from  drawings 
especially  made  for  the  book.  Forty  new  illustrations  and  full-])age 
plates  in  color  and  monochrome  have  been  added.  0})erative  proce- 
dures are  set  forth  as  they  take  ]ilace  step  by  step  in  numerous  series 

7 


8  PREFACE  TO   THE  FIFTH  EDITION. 

of  drawings ;  for  example,  tweaty-two  drawings  describe  the  steps  of 
the  different  operations  of  Myomectomy  and  Hysteromyomectomy  ; 
thirty-two  explain  Perineal  Lacerations  and  the  steps  of  Perineor- 
rhaphy. The  surgical  instrument  catalogue  element  has  been  elimi- 
nated, all  instruments,  so  far  as  practicable,  being  shown  as  they  appear 

in  actual  work. 

E.  C.  D. 

100  State  Street,  Chicago. 
1908. 


CONTENTS. 


PART    I. 
GENERAL   PRINCIPLES. 


INTKODUCTION [^ 

CHAPTER  I. 

THE  PHYSIOLOGICAL  PEEIODS  IN  THE  LIFE  OF  WOMAX 21 

CHAPTER  II. 
SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE 32 

CHAPTER  III. 
DIAGNOSIS 51 

CHAPTER  IV. 
LOCAL  TREATMENT 91 

CHAPTER  V. 
MINOR  OPERATIONS ,    .    .     99 

CHAPTER  VI. 
MAJOR   OPERATIONS 120 

CHAPTER  VII. 
DRAINAGE   IN   MAJOR   OPERATIONS 138 

CHAPTER  VIII. 
AFTER-TREATMENT   IN   MAJOR   OPERATIONS 148 

CHAPTER  IX. 

THE  RELATIONS  OF  DRESS  TO  THE  DISEASES  OF  WOMEN 159 

'J 


10  CONTENTS.    . 

PART   II. 

INFECTIONS,   INFLAMMATIONS,   AND   ALLIED 
DISORDERS. 


CHAPTER  X. 

PAGE 

GENERAL  CONSIDEEATIONS  OF  INFECTION  AND   INFLAMMATION  OF 

THE  EEPEODUCTIVE  ORGANS 16<r 

CHAPTER  XI. 
VULVITIS,  VULVOVAGINITIS,  VAGINITIS 174 

CHAPTER  XII. 

ECZEMA    VULVAE,   HERPES    VULV^,    KRAUROSIS    VULV^,    PRURITUS 

VULV^,  HYPERESTHESIA  VULVE,  VAGINISMUS 192 

CHAPTER  XIII. 
METRITIS— INFLAMMATION  OF  THE  UTERUS 202 

CHAPTER  XIV. 
ACUTE  METRITIS 207 

CHAPTER  XV. 
CHRONIC   ENDOCERVICITIS 217 

CHAPTER  XVI. 
CHRONIC  ENDOMETRITIS 226 

CHAPTER  XVII. 

CHRONIC  ENDOMETRITIS  (Continued) 238 

CHAPTER  XVI  n. 
CHRONIC   METRITIS 250 

CHAPTER  XIX. 
PELVIC  INFLAMMATION 257 

CHAPTER   XX. 

PELVIC  CELLULITIS 260 

CHAPTER  XXI. 

INFLAMMATION  OF  THE  UTERINE   APPENDAGES— SALPINGITIS,  OVA- 
RITIS, PELVIC   PERITONITIS 268 


CONTENTS.  11 

CHAPTER  XXII. 

PAGE 

NON-SURGICAL    TREATMENT    OF     PELVIC    INFLAMMATION— SALPIN- 
GITIS, OVARITIS,  AND  PELVIC  PERITONITIS 287 


CHAPTER  XXIII. 

SURGICAL  TREATMENT  OF  SALPINGITIS,  OVARITIS,  AND  PELVIC  PERI- 
TONITIS   291 

CHAPTER  XXIV. 

URETHRITIS— URETHRITIS  COMPLICATED  BY  PROLAPSE  OF  URETHRA 
—URETHRITIS    COMPLICATED    BY    SUBURETHRAL   ABSCESS— CYS- 
.  TITIS— PYELITIS :    .    .    333 


PART   III. 
TUMORS,   TUBAL   PREGNANCY,   MALFORMATIONS. 


CHAPTER  XXV. 
TUMORS  OF  THE  VULVA  AND  VAGINA 357 

CHAPTER   XXVI. 
TUMORS  OF  THE   UTERUS— MYOMA 366 

CHAPTER   XXVII. 
TUMORS  OF  THE   UTERUS   (Continued) 380 

CHAPTER   XXVIII. 
TUMORS  OF  THE  UTERUS   (Continued) 411 

CHAPTER   XXIX. 
TUMORS  OF  THE  UTERUS   (Continued) 431 

CHAPTER   XXX. 
TUMORS  OF  THE  UTERUS   (Continued) 434 

CHAPTER   XXXI. 
SOLID  TUMORS  OF  THE  OVARY 436 

CHAPTER   XXXII. 

CLASSIFICATION,    MODE    OF    DEVELOPMENT,    AND     PATHOLOGY    OF 

OVARIAN  AND  PAROVARIAN  CYSTS,  AND  OVARIAN  HYDROCELE  .     4.-58 


12  CONTENTS. 

CHAPTER  XXXIII. 

PAGE 

SECONDARY  CHANGES— SYMPTOMATOLOGY— DIAGNOSIS,  PROGNOSIS, 
AND  DIFFERENTIAL,  DIAGNOSIS  OF  OVARIAN  AND  PAROVARIAN 
CYSTS 451 

CHAPTER   XXXIV. 
OVARIOTOMY 470 

CHAPTER   XXXV. 

TUMORS    OF    THE    FALLOPIAN    TUBES,    BROAD    LIGAMENTS,    ROUND 

LIGAMENTS,    AND   URINARY   ORGANS 481 

CHAPTER   XXXVI. 

TUBAL   PREGNANCY 486 

CHAPTER   XXXVII. 

EMBRYOLOGY  OF  THE  GENITALIA  AND  CONGENITAL  MALFORMATIONS   503 

CHAPTER   XXXVIII. 
CONGENITAL   GYNATRESIA   WITH   RETAINED  MENSTRUAL   FLUID  .    .    530 


PART    IV. 
TEAUMATISMS. 

CHAPTER   XXXIX. 

NON-PUERPERAL   INJURIES  OF    THE   VULVA,  VAGINA,   AND  CERVIX 

UTERI 537 

CHAPTER   XL. 
LACERATIONS   OF  THE   PERINEUM   AND  PERINEAL  REGION 538 

CHAPTER   XLI. 
PERINEORRHAPHY 549 

CHAPTER   XLII. 
PUERPERAL   LACERATION   OF   THE   CERVIX   UTERI 565 

CHAPTER   XLIII. 
GENITAL  FISTULA 593 


CONTENTS.  13 

PAET   V. 

DISPLACEMENTS  OF  THE  UTERUS  AND  OTHER 
PELVIC  ORGANS. 


CHAPTER   XLIV. 

PAGE 

DISPLACEMENTS   OF   THE   UTERUS G27 

CHAPTER   XLV. 

MAL-L0C;ATI0NS   of  the   uterus 635 

CHAPTER   XLVI. 

ETIOLOGY,  SYMPTOMS,  COURSE,  DIAGNOSIS,  AND  PROGNOSIS  OF  RETRO- 
VERSION  AND    RETROFLEXION 668 

CHAPTER   XLVII. 
TREATMENT   OF   RETROVERSION    AND   RETROFLEXION 675 

CHAPTER   XLAan. 

ANTEVERSION   AND   ANTEFLEXION    OF    THE   UTERUS:     TORSION  OF 

THE  UTERUS 710 

CHAPTER   XLIX. 
INVERSION  OF  THE  UTERUS.     HERNIA  OF  THE  UTERUS  AND  OVARY  .    729 

PART   VI. 

DISORDERS   OF   MENSTRUATION   AND   STERILITY 
AND   INCONTINENCE   OF   URINE. 

CHAPTER  L. 
PREMATURE   MENSTRUATION  AND   PROTRACTED   MENSTRUATION  .    .    743 

CHAPTER   LI. 
AMENORRHCEA  AND  SCANTY  MENSTRUATION 745 

CHAPTER   LH. 

UTERINE  HEMORRHAGE— MENORRHAGIA   AND  METRORRHAGIA    ...    750 

CHAPTER   LIII. 
DYSMENORRHCEA  AND   PERIODIC  INTERMENSTRUAL   PAIN 756 

CHAPTER  LIV. 
STERILITY 763 

CHAPTER  LV. 
INCONTINENCE  OF  URINE  IN  WOMEN 771 


PRINCIPLES   AND   PRACTICE   OF 
GYNECOLOGY. 


INTRODUCTION.! 

The  general  law  that  progress  in  any  direction  is  characterized  by 
specialization,  with  its  attendant  classification  and  simplicity,  has  been 
exemplified  in  no  great  movement  more  strongly  than  in  the  develop- 
ment of  scientific  medicine  during  the  last  three  decades.  The 
late  Samuel  D.  Gross,  fi3remost  general  surgeon  of  his  day,  after  a 
long  period  of  active  service  as  author,  teacher,  and  practitioner, 
writing  the  preface  to  the  sixth  edition  of  his  System  of  Surgery  in 
October,  1882,  thus  early  gives  credit  to  specialization  for  the  unpar- 
alleled advances  in  modern  surgery.  Specialization,  he  says  in  sub- 
stance, has  penetrated  with  its  methods  and  instruments  of  research 
the  innermost  recesses  of  the  human  body,  and  in  a  comparatively 
brief  period  has  achieved  triumphs  which  general  surgery  perhaps 
never  would  have  accomplished. 

In  the  earlier  period,  when  the  specialist  confined  himself  to  a  par- 
ticular organ,  disregarding  its  relations  to  the  general  system,  when 
frequently  exclusive  books  appeared  from  this  author,  for  example,  on 
the  stomach,  or  from  that  one  on  the  brain,  specialization  was  cumber- 
some, narrow,  ineffective,  and  a  hindrance  to  scientific  medicine. 
Finally,  the  logical  tendency  to  study  each  part,  not  by  itself,  but  in 
its  essential  relations  to  the  whole  system,  gave  rise  to  such  a  welding 
together  into  a  great  unit  of  all  the  specialties  that  any  organ,  even 
though  recognized  in  its  individual  importance  and  autonomy,  at  the 
same  time  was  equally  recognized  as  subject  to  general  law.  It  then 
became  apparent  that  physiological  and  pathological  processes,  such  as 
circulation  and  infection,  were  substantially  the  same  whatever  the 
organ  involved.  Order  then  came  out  of  chaos  and  specialization 
became  a  potent  factor  in  the  simplification  and  progress  of  medicine. 
From  this  time  forward,  laryngology,  rhinology,  orthopedics,  ophthal- 
mology, neurology,  climatology,  state  medicine,  obstetrics,  and  gyne- 
cology rapidly  developed  and  became  identified  in  all  parts  of  the 
civilized  world  with  remarkable  groups  of  men  who  have  strengthened 
scientific  medicine  by  building  up  these  departments  to  an  extent  un- 
equaled  in  any  other  period  of  history. 

In  nearly  all  the  medical  teaching  centers  of  America  and  Europe 
the  most  conspicuous  specialty  of  modern  medicine,  gynecology, 
has  enjoyed  full  recognition  not  only  in  the  day  of  its  early  struggle, 

1  From  the  author's  presidential  address,  delivered  at  the  annual  meeting  of  the  American 
Gynecological  Society  at  Niagara  Falls,  1905. 

2  17 


18  PETNCIPLES  AND  PRACTICE. 

but  later  in  the  period  of  its  highest  development,  with  the  signifi- 
cant result  that  in  dignity  of  position  and  in  output  of  scientific  prod- 
uct it  has  in  many  respects  outbalanced  the  department  of  general 
surgery  itself. 

The  progress  of  gynecology  has  been  marked  by  two  pronounced 
periods :  The  first  was  an  earlier  period,  characterized  by  great 
activity  in  the  perfection  of  numerous  plastic  operations  on  the 
vao-inal  side  of  the  pelvic  floor.  This  development  of  minor  plastic 
surgery  calls  to  mind  many  familiar  names  at  home  and  abroad,  most 
conspicuous  among  them  the  names  of  two  pioneers,  Emmet  and 
Marion-Sims.  The  second  or  later  period  was  one  of  tremendous 
progress  in  the  surgery  of  the  obverse  abdominal  side  of  the  pelvic 
floor.  Now  a  third  period  is  before  us  in  which  gynecology  has  taken 
to  itself  the  whole  field  of  abdominal  surgery. 

The  early  gynecologist  was  logically  led  by  the  anatomical,  physio- 
logical, and  pathological  unity  of  the  reproductive  organs  into  the 
peritoneal  surgery  of  the  pelvic  cavity  and  thence  by  anatomic  con- 
tinuity into  that  of  the  upper  abdomen.  In  peritoneal  surgery,  his 
educated  touch,  his  special  surgical  judgment,  and,  above  all,^  his 
training  in  the  technic  of  plastic  gynecology,  placed  him  on  a  decided 
vantage  ground  over  the  general  surgeon. 

This  widening  of  limitations  to  include  the  territory  of  abdominal 
surgery  has  given  rise  to  an  extraordinary  and  altogether  interesting 
eflbrt  on  the  part  of  the  general  surgeon  to  promulgate  the  erroneous 
idea  that  the  gynecologist  has  become  a  general  surgeon  and  thereby 
has  forced  gynecology  as  a  specialty  into  the  background,  where  any 
one,  even  without  special  preparation,  may  practice  it.  Thus  we  hear 
of  "The  Merging  of  Gynecology  into  General  Surgery,"  "The 
Passing  of  a  Great  Specialty,"  "  The  Expansion  or  Obliteration  of  a 
Specialty."  We  are  told  that  gynecology  is  a  finished  subject,  and 
that  "  he  who  runs  may  read,"  that  it  is  only  a  matter  of  a  few  opera- 
tive procedures,  that  the  technic  of  it  is  now  perfected  and  ready- 
made  for  the  hand  of  any  one,  that  soon  in  medical  journals,  in  text- 
books, in  medical  schools,  in  societies  and  hospitals,  gynecology  will 
be  merged  into  general  surgery  and  the  name  will  be  forgotten. 

In  considering  this  most  recent  attitude  toward  gynecology  I  do  not 
refer  to  the  practitioner  who  may  be  so  situated  that  the  most  compe- 
tent experts  are  not  available ;  necessarily  he  may  be  compelled,  to 
the  best  of  his  ability,  not  for  himself  alone,  but  in  the  interestof  liis 
patient,  to  undertake  not  only  gynecology,  but  all  the  other  specialties, 
nor  do  I  deny  that  a  general  surgeon  of  sufficient  versatility  may 
carry  on  miscellaneous  surgical  work  and  at  the  same  time,  if  he  will 
undergo  the  necessary  long  and  careful  training,  may  acquire  the 
special  judgment,  the  special  diagnostic  and  operative  technic,  essen- 
tial to  proficiency  in  the  practice  of  a  great  specialty  ;  but  this  admis- 
sion does  not  weaken  the  indictment  which  I  would  offer  against  a 
type  of  general  surgeon,  whose  number  increases  day  by  day,  whose 
relation  to  this  specialty  is  the  outcome  of  a  reasoning  all  his  own,  a 
reasoning  from  the  plausible  premise  that  "  the  gynecologist,  having 
perfected  and  simplified  his  specialty,  has  found  it  too  narrow  and  has 


INTR  OD  UCTION.  1 9 

expanded  "  to  the  specious  conclusion  that  gynecology  is  an  insig- 
nificant branch  and  that  the  gynecologist  therefore  has  undertaken 
general  surgery.  This  logic  gives  rise  to  a  sophistry  :  if  the  gynecol- 
ogist is  a  general  surgeon,  conversely  the  general  surgeon  is  a  gyne- 
cologist. As  the  times  change  and  we  change  with  them,  this  type  of 
universal  operator,  quick  to  seize  on  and  turn  to  his  own  account  the 
intimation  that  this  specialty  has  passed,  with  refinement  neither  of 
diagnostic  nor  operative  technic,  with  no  ajDpreciation  of  his  limita- 
tions, hypnotized  by  an  apprenticeship  of  six  weeks  in  some  post- 
graduate school,  or  by  no  apprenticeship  at  all,  emboldened  by  the 
fact  that  no  one  has  called  him  to  account,  would  make  gynecology 
crude  and  common,  would  persuade  the  public  and  the  profession  that 
it  is  a  mere  caudal  appendix  to  surgery  on  which  no  one  fears  to 
tread.  Let  us  for  the  moment  dismiss  the  general  discussion  of  the 
subject  and  imagine  a  private  hospital  conducted  under  certain  practi- 
cal conditions  of  business  management  and  promotion,  with  a  year  of 
active  practice  in  capital  operations,  most  of  them  belonging  to  this, 
forsooth,  insignificant  branch  of  surgery  and  a  mortality  of  70  per 
cent.,  and  then  with  this  experience  as  a  background,  going  on  for 
an  additional  few  weeks  to  eleven  more  consecutive  abdominal  opera- 
tions and  100  per  cent,  of  mortality.  This  is  an  extreme  but  never- 
theless historical  example,  taken  not  from  the  dark  ages  of  surgery,  but 
from  our  own  times.     It  would  be  painful  to  expose  other  instances. 

Gynecology  has  not  passed.  We  are  not  general  surgeons.  We 
are  specialists  in  the  diseases  of  women,  and  as  our  later  transactions 
abundantly  show,  we  are  to  a  rapidly  increasing  extent  specialists  also 
in  the  wider  field  of  abdominal  surgery,  a  field  in  which  the  account 
on  the  ledger  as  it  stands  to-day  will  show  general  surgery  in- 
debted to  us  for  a  great  part  of  its  practical  and  scientific  progress  ; 
the  claim  is  valid,  for  we  were  blazing  the  trail  through  this  territory 
when  it  was  an  untrodden  wilderness,  and  it  is  ours  by  right  of  discov- 
ery ;  we  were  giving  laws  to  govern  the  conduct  of  the  stranger  in 
this  field  when  it  was  unknown  and  unconquered,  and  it  is  ours  by 
right  of  conquest ;  we  received  from  the  pioneers,  our  teachers,  some 
of  whom  are  with  us  now,  the  principles  and  precepts  on  which  has 
been  built  up  this  most  aggressive  department  of  surgery,  and  it  is 
ours  by  right  of  inheritance. 

Marion-Sims  was  not  a  general  surgeon  when  he  laid  down  the 
laws  which  to-day  govern  the  surgery  of  the  gall-bladder,  when  he 
foreshadowed  the  modern  treatment  of  gunshot  wounds  of  the  abdo- 
men and  thereby  set  in  motion  a  tide  of  general  abdominal  surgery  of 
which  the  ebb  flow,  particularly  in  the  upper  zones  of  the  abdomen, 
where  we  have  joined  liands  with  the  general  surgeon,  is  already 
overdue.  Do  the  traditions  Avhich  properly  belong  to  us  count  for 
nothing?  Shall  we  retire  into  the  background?  Shall  we  organize  a 
society  of  the  Cincinnati,  enter  into  our  second  childhood,  and  live  on 
the  memories  of  the  past  ?  Is  our  work  done  ?  Shall  Ave  say, 
"■  Troy  has  been,  we  have  been  Trojans  "  ?  If  our  work  is  done,  why 
should  we  not  go  at  once  into  voluntary  liquidation?  Whv  should 
a  special  society  hold  another  meeting  ?     But  so  long  as  in  the  diseases 


20  PRINCIPLES  AND  PRACTICE. 

of  women  there  are  practical  and  scientific  problems  to  be  solved, 
our  work  is  not  done.  Does  not  the  increased  strain  of  modern 
life,  notwithstanding  impi-oved  know^ledge  of  sanitation  and  hygiene, 
bring  about  exaggerations  of  pathology  which  will  demand  not  less 
but  more  of  the  gynecologist?  If  we  do  not  respect  our  own 
specialty,  who  will  ?  Let  us  consider,  for  example,  the  every-day  sub- 
ject of  dysmenorrhea,  about  which  as  yet  we  know  but  little ;  the 
causes  of  eclampsia,  of  which  we  know  less ;  the  purpose  of  menstru- 
ation, of  which  we  know  nothing ;  the  unknown  conditions,  which  in 
one  case  will  supply  defense  against  general  septic  peritonitis  and 
in  another  apparently  similar  case  will  open  the  way  to  a  rapidly 
fatal  peritoneal  infection.  Let  us  reflect  that  we  have  not  spoken  the 
last  word  on  the  surgical  treatment  of  descent,  retroversion,  and  other 
deviations  of  the  pelvic  organs ;  let  us  consider  whether  in  the  next 
thirty  years  we  or  the  general  surgeons  are  going  to  make  such  im- 
provements in  practical  gynecology  that  the  hysteropexies,  the  hys- 
terorrhaphies,  the  suspensions,  the  fixations,  and  a  number  of  other 
procedures  may  look  to  our  successors  as  crude  and  irrational  as  the 
clamp  and  routine  use  of  the  drainage-tube  in  ovariotomy  look  to  us 
at  the  present  time. 

And  now,  supplementary  to  this  discussion,  may  I  offer  a  sugges- 
tion? In  recent  years,  abdominal  surgery  has  so  far  engrossed  the 
mind  of  the  gynecologist,  not  to  mention  that  of  the  general  surgeon, 
that  by  comparison  the  minor  plastic  work  to  some  extent  has 
been  neglected  or  given  into  incompetent  hands.  It  is  perhaps  not  too 
much  to  say  that  our  fathers  in  their  day  did  better  plastic  surgery  than 
we  are  doing  in  ours.  Indeed,  a  revival  of  interest  may  be  necessary 
in  order  to  save  this  part  of  gynecology  from  becoming  a  lost  art. 
There  is  now  accumulating  a  very  appreciable  number  of  ]5atients  on 
whom  plastic  operations,  some  of  them  repeated  on  the  same  patient 
many  times  over,  have  been  performed  with  indifferent  or  injurious 
results.  Many  such  patients  need  to  have  the  work  undone  or  done 
over  again.  And  this  class  of  cases  now,  therefore,  is  making  an  in- 
creasing demand  on  the  attention  of  the  competent  gynecologist.  It  is 
time,  therefore,  without  losing  sight  of  the  claims  of  capital  surgery,  to 
bestow  adequate  attention  on  the  homely  every-day  problems  of  minor 
gynecology. 


PARTI. 
GENERAL  PRINCIPLES. 


CHAPTER   I. 

THE  PHYSIOLOGICAL  PERIODS  IN  THE  LIFE  OF  WOMAN. 

In  embryonic  life  and  early  infancy  the  physiological  lines  that        IMaCj 
mark  the  distinction  of  sex  nearly  coincide,  and  anatomical  diiferences  '. 

have  little  more  than  potential  significance ;  as  childhood  recedes  these 
lines  diverge ;  as  maturity  progresses  they  separate  more  and  more  ; 
finally,  in  old  age  they  draw  together  until  in  the  second  childhood,  as 
in  the  first,  they  again  nearly  coincide.  Development  from  infancy  to 
maturity  and  decline  from  maturity  to  senility  are  common  alike  to 
man  and  to  woman.  In  man  the  anatomical  and  physiological 
changes  from  the  time  of  birth  to  the  period  of  youth  and  virility  and 
the  cessation  of  sexual  power  in  old  age  are  gradual  and  even  proc- 
esses, relatively  free  from  special  outlay  of  energy,  unmarked  by 
specially  critical  periods,  and  unattended  by  pronounced  nervous  or 
mental  disturbance.  In  woman  these  transition-periods  are  charac- 
terized by  greater  expenditure  of  energy,  by  more  rapid  sexual 
change,  and  by  more  distinct  nervous  and  psychic  phenomena ;  they 
are  the  critical  turning-points  in  her  life.  At  the  first  crisis — puberty 
— the  reproductive  organs,  more  complicated  than  those  of  the  male 
and  hitherto  unproductive,  suddenly  become  the  centre  of  great  and 
rapid  development;  from  this  period  forward  until  the  second  and 
final  crisis — the  menopause — her  vital  forces  are  especially  subject 
to  the  exactions  of  menstruation  and  maternity. 

The  life  of  woman  may  be  divided  into  five  periods,  each  corre- 
sponding to  a  special  phase  of  her  sexual  existence  ;  they  are  infancy, 
pjiberty,  maturity,  the  menopause,  and  senility. 

INFANCY. 

Infancy  includes  the  first  ten  or  twelve  years  of  life,  and,  although 
a  period  of  great  pathological  significance,  is  rather  a  subject  of  paedi- 
atrics than  of  gynecology.  During  this  period  the  reproductive 
organs  are,  for  the  most  part,  functionally  dormant ;  they  are  under- 
going a  gradual  development  preparatory  to  the  more  rapid  and  radi- 
cal changes  of  puberty.  Infections  and  inflammations  occasionally 
arise ;  neoplasms  and  traumatisms  are  rare ;  congenital  malforma- 
tions, if  present,  usually  are  overlooked  until  the  period  of  puberty 
or  maturity,  when,  by  reason  of  some  defect  in  the  function  of  naen- 

21 


22  GENERAL  PRINCIPLES. 

struation,  coitus,  or  parturition,  they  become  evident ;  displacements 
of  the  infantile  uterus,  although  possible,  have  little  or  no  clinical 
significance. 

PUBERTY. 

Puberty  is  the  critical  transition-period  in  which  the  child  becomes 
the  woman.  The  relations  and  influences  of  this  period  are  funda- 
mental, both  in  the  reproductive  organs  and  in  the  entire  woman,  so 
that  upon  the  normal  course  of  it  depends  much  of  the  after  health, 
comfort,  and  usefulness  of  the  individual. 

The  Anatomical  Basis  of  puberty  is  the  full  physical  develop- 
ment of  the  reproductive  organs.  The  infantile  uterus  is  small,  soft, 
and  plastic  ;  it  varies  in  size  from  that  of  early  infancy  (Figure  1)  to 
that  of  the  child-uterus  just  before  puberty  ;  at  the  beginning  of 
puberty  the  uterine  canal  would  measure,  perhaps,  two  inches ;  when 
fully  developed  at  the  end  of  puberty  it  should  measure  two  and  one- 
half  inches. 

Figure  1. 


uterus,  Fallopian  tubes,  and  ovaries  of  an  infant  one  month  old.    Natural  size. 


The  cervix  of  the  infantile  uterus  is  two-thirds,  and  the  corpus 
one-third,  as  long  as  the  entire  organ.  These  proportions  when  the 
organ  is  fully  developed  at  the  end  of  puberty  are  reversed — that  is, 
the  corpus  represents  two-thirds  and  the  cervix  only  one-third  of  the 
length  of  the  mature  uterus.  At  maturity  the  longitudinal  axis 
extending  from  the  os  externum  to  the  fundus  measures  three  inches ; 
the  transverse  axis  of  the  corpus  uteri  measured  laterally  from  horn 
to  horn  is  two  inches,  and  measured  by  the  longest  anteroposterior 
diameter  is  one  inch.  The  fundus  of  the  infantile  uterus  is  flat ;  the 
fundus  of  the  mature  uterus  is  convex  and  dome-shaped.  The  mucosa 
of  the  infantile  uterus  presents  an  arbor  vitce  arrangement  throughout 
the  corpus  and  cervix ;  at  maturity  this  arrangement  is  confined  to 
the  cervix. 

Developmental  changes  similar  in  extent  to  those  above  outlined 
occur  in  the  ovaries  and  in  the  other  genital  organs.  Puberty  is 
marked  also  by  enlargement,  of  the  pelvis  and  breasts,  by  the  appear- 


THE  PHYSIOLOGICAL  PERIODS  IN  THE  LIFE  OF   WOMAN.      23 

ance  of  hair  on  the  mons  veneris,  vulva,  and  armpits,  and  by  general 
rounding  out  of  the  form  with  adipose  tissue. 

The  Physiological  Features  of  puberty  are  the  onset  of  menstru- 
ation and  ovulation  and  notable  psijchic  changes,  all  of  which  indicate 
that  the  reproductive  organs  and  the  sexual  nervous  organization  are 
approaching  maturity  and  that  the  girl  is  preparing  for  maternity. 

Menstruation. 

Menstruation  is  characterized  by  a  bloody  mucous  discharge  from 
the  uterus  ;  this  discharge  contains  epithelial  cells  from  the  uterus  and 
vagina ;  it  begins  with  puberty,  and,  unless  interrupted  by  uterogesta- 
tion  and  lactation  or  by  disease,  normally  recurs  in  regular  periods 
until  the  time  of  the  menopause.  The  phenomena  of  menstruation 
are  both  general  and  local. 

I.  The  General  Phenomena  of  Menstruation  are  as  follows : 

1.  Slight  elevation  of  pulse-rate  and  temperature  at  the  onset. 

2.  Tendency  to  slight  physical  depression  and  inactivity. 

3.  Sensations  of  heat  and  cold. 

4.  Swelling  of  the  breasts  and  thyroid  gland. 

5.  Discomfort  and  throbbing  in  the  head,  weight  in  the  pelvis 

and  back,  and  irritability  of  the  bladder. 
These  disturbances  are  subject  to  wide  variations.  In  some  cases 
they  are  absent ;  in  others  they  are  so  slight  as  almost  to  escape  notice, 
or  so  severe  as  to  render  life  miserable  and  useless.  Painful  men- 
struation— that  is,  dysmenorrhoea — is  always  proof  of  some  pathologi- 
cal condition.     See  Chapter  LIII. 

II.  The  Local  Phenomena  of  Menstruation  are  recognized  in 
three  stages : 

1.  Stage  of  invasion — discharge  of  mucus. 

2.  Stage  of  persistence — flow  of  blood. 

3.  Stage  of  decline — discharge  of  mucus. 

Discharge  of  mucus  before  and  after  the  flow  of  blood  is  an  essen- 
tial part  of  the  menstrual  flux  ;  in  lower  animals  the  menstrual  dis- 
charge, if  present  at  all,  is  entirely  of  mucus.  In  the  human  race 
the  lower  the  intellectual  scale,  the  greater  the  relative  quantity  of 
mucus  ;  the  higher  the  scale,  the  greater  the  relative  quantity  of  blood. 

Amenorrhoea. — Amenorrhoea  is  the  absence  of  menstruation ;  it 
may  be  physiological  or  pathological. 

Physiological  Amenorrhoea. — Physiological  absence  of  menstruation 
occurs : 

1.  Prior  to  puberty. 

2.  At  irregular  intermenstrual  periods  during  the  establishment 

of  puberty. 

3.  During  pregnancy  and  lactation. 

4.  At  irregular  intermenstrual  periods  during  the  climacteric. 

5.  After  the  menopause. 

Pathological  Amenorrhoea. — A  discussion  of  the  pathological  causes 
of  amenorrhoea  may  be  found  in  Chapter  LI. 

Age  of  First  Menstruation. — The  age  at  which  menstruation  first 


24  GENERAL  PRINCIPLES. 

appears  varies  widely  with  individuals.  Climate  and  heredity,  espe- 
cially the  former,  are  determining  factors.  In  the  United  States  it 
first  appears  on  the  average  about  the  fourteenth  or  fifteenth  year, 
sometimes  as  early  as  the  ninth  or  tenth,  or  as  late  as  the  eighteenth. 
In  the  Arctics  the  average  age  is  sixteen  years  and  in  the  tropics  ten 
or  eleven. 

Precocious,  Protracted,  and  Scanty  Menstruation  will  be  pre- 
sented in  Chapters  L.  and  LI. 

Frequency  of  Menstruation. — The  human  menstrual  cycle  covers 
a  period  of  about  twenty-eight  days.  Variations  of  a  few  days  are 
common  and  usually  harmless. 

Quantity  of  Menstrual  Discharge  and  Duration  of  Flow. — The 
average  amount  of  menstrual  fluid  lost  in  a  single  period  is  from  six  to 
eight  ounces ;  the  minimum  is  two,  and  the  maximum,  ten  ounces. 
A  plethoric,  well-nourished  woman  may  menstruate  freely  for  eight 
or  ten  days  without  ill  effect,  and  may  lose  an  amount  of  blood  which 
would  undermine  seriously  the  strength  of  an  anaemic,  poorly  nourished 
woman.  What  would  be  normal  for  one  woman,  therefore,  would  be 
abnormal  for  another.  The  usual  means  of  estimating  the  quantity 
of  blood  lost  is  by  counting  the  napkins  used.  The  average  number 
is  fourteen.  Nothing  approaching  exactness  is  gained  by  this  method, 
since  napkins  vary  in  size  and  capacity  for  absorption,  and  since  one 
w^oman  will  tolerate  an  oversaturated  napkin  while  another  will 
scarcely  permit  the  soiling. 

Anatomy  of  Menstruation. — Although  menstruation  has  been 
the  subject  of  many  strange  superstitions  and  speculations,  yet  nothing 
is  known  of  the  utility,  cause,  or  significance  of  it.  Numerous  con- 
flicting opinions  concerning  the  anatomy  of  menstruation  have  been 
put  forth  :  one,  that  the  corporeal  mucosa  is  stripped  oflP  clear  to  the 
muscular  layer  at  each  recurring  flow  ;  another,  that  only  the  epithe- 
lial layer  is  shed ;  another,  that  a  newly  organized  tissue  is  developed 
during  the  intermenstrual  period,  and  that  this  alone  is  cast  off.  The 
notion  that  the  surface  epithelium  is  thrown  off  in  the  process  of 
menstruation  has  arisen  from  faulty  methods  of  investigation.  Ob- 
servations made  on  the  uteri  of  women  who  had  died  from  freez- 
ing or  from  infectious  disease  during  menstruation,  or  upon  uteri 
removed  twenty-four  hours  or  longer  after  death ;  or  upon  freshly 
removed  specimens  in  which  the  surface  epithelium  had  been  injured 
in  the  handling,  have  supported  the  conclusion  that  the  surface  epithe- 
lium is  shed  during  menstruation,  when  in  reality  the  loss  of  epithe- 
lium was  post  mortem.  Gebhard,  of  Berlin,  has  put  forth  the  correct 
interjjretation  of  the  anatomical  changes  of  menstruation.  His  ob- 
servations upon  fresh  material  carefully  prepared  demonstrate  that 
in  menstruation  there  is  no  shedding  of  the  surface  epithelium. 

Three  stages  of  menstruation  are  recognized  : 

1.  Premenstrual  congestion.     Plate  II.,  Figure  1. 

2.  Subepithelial  hematoma.     Plate  II.,  Figure  2. 

3.  Bursting  of  blood  through  surface  epithelium  and  post-men- 
strual absorption.     Plate  II.,  Figure  3. 

The  connective  tissue  of  the  endometrium  is  of  the  embryonal  type, 


PLATE   IT 


FIGURE     1. 


rnl  #^- '  T- 


FIGURE   2 


jii^^ 


FIGURE   3. 


» 


Cv/  ^^-M-UVCI^- 


Anatoniy  of  Menstruation  (Modified  from  Gebhard). 

Figure  1.  Stage  of  pre-menstrual  eongestiun. 
Figure  2.  Stage  of  sub-epithelial  hsematoma. 
Figure  3.     Stage  of  bursting  of  blood  through  the    surface  epithelium.     !)l)  dianielers. 


THE  PHYSIOLOGICAL  PERIODS  IN  THE  LIFE  OF  WOMAN.     25 

and  is  permeated  with  delicate  blood-vessels.  These  vessels  partici- 
pate in  the  general  pelvic  congestion  that  precedes  menstruation,  and 
readily  give  forth  an  effusion  of  blood  into  the  embryonal  connective 
tissue  ;  the  effused  blood  takes  the  direction  of  least  resistance — that 
is,  to  the  surface  of  the  endometrium.  Under  the  surface  epithelium 
the  blood  collects  in  small  quantities,  forming  what  may  be  termed 
subepithelial  hsematomata.  With  increasing  pressure  the  blood  passes 
between  the  epithelial  cells  of  the  surface,  elevating  groups  of  cells 
from  the  basement  membrane  and  occasionally  breaking  off  small 
fragments  of  epithelium.  With  lessening  blood-pressure  the  hemor- 
rhage becomes  less  abundant,  and  finally  the  blood  ceases  to  pass 
through  the  epithelial  barrier ;  then  follows  absorption  of  the  effused 
blood  from  the  connective  tissue  and  subepithelial  spaces.  The 
epithelium  that  had  been  lifted  from  the  basement  membrane  sinks 
back  into  its  former  relations.  Any  minute  areas  accidentally  denuded 
are  quickly  covered  by  new  epithelium  regenerated  from  adjoining 
surface  epithelium  and  gland  epithelium.  Such  are  the  anatomical 
events  of  menstruation. 

Ovulation. 

Ovulation  involves  the  maturing  and  rupture  of  the  Graafian  follicle 
and  the  escape  of  the  ovum.     Formerly,  menstruation  was  commonly 

Figure  2. 


Section  of  ovary  (magnified).  1.  Outer  covering.  2.  Graafian  follicles  in  earliest  stage  of 
development.  3.  Graafian  follicles  in  more  advanced  stage  of  development :  the  largest  follicle 
is  almost  mature.  3'.  Follicle  from  which  ovum  has  escaped.  4.  Slightly  developed  follicles. 
5.  Peripheral  stroma.  6.  Central  stroma.  7.  Corpus  luteum.  Modified  from  Schron's  drawing 
of  the  ovary  of  a  cat. 

thought  to  be  an  external  manifestation  of  ovulation  and  dependent 
upon  it ;  but  whatever  may  be  the  relation  between  these  two  func- 
tions, that  of  cause  and  effect,  for  the  following  reasons,  is  no  longer 
tenable  : 

1.  There  is  a  cyclical  periodicity  in  menstruation,  and  there  is  no 
such  periodicity  in  the  maturing  of  the  Graafian  follicle  and  discharge 
of  the  ovum  ;  the  process  of  ovulation  is  continuous,  and  occurs  even 
in  the  mature  foetus. 


26 


GENERAL  PRINCIPLES. 


2.  Menstruation  sometimes  continues  after  removal  of  the  ovaries. 

3.  On  opening  the  abdominal  cavity  during  menstruation  one  fre- 
quently fails  to  find  a  fresh  corpus  luteum  in  either  ovary  ;  on  the 
contrary,  he  frequently  finds  it  during  the  intermenstrual  period. 

4.  Ovulation  occurs  in  the  absence  of  menstruation  ;  this  is  proved 
by  the  fact  that  conception  may  take  place  during  the  period  of  lacta- 
tion, and  even  after  the  menopause. 

Although  the  dependence  of  menstruation  on  ovulation  has  not 
been  established,  there  is  yet  reason  to  conclude  that  ovulation  and 
menstruation  are  both  under  the  control  of  the  same  nerve  apparatus, 

Figure  3. 


Mature  ovary,  FaUopian  tube,  and  uterus,  from  a  woman  twenty-five  years  ot  age. 

Natural  size. 


and  that  the  nerves  of  the  uterus  and  ovaries  have  a  certain  co-ordi- 
nation. 

Care  during  Puberty. — Although  the  appearance  of  menstrua- 
tion indicates  that  maternity  is  possible,  it  by  no  means  follows  that 
the  development  of  the  individual  is  complete  at  this  time,  nor  that 
she  is  capable  of  fulfilling  the  requirements  of  maternity.  Before  the 
twentieth  year  the  nervous  system  is  unequal  to  the  strain  of  child- 
bearing  and  child-rearing ;  the  muscles  are  inadequate  to  the  carrying 
and  expulsion  of  the  child  ;  and  the  pelvis  is  often  too  small  to  give  it 
safe  exit.  The  period  of  puberty  should  be  taken  as  extending  not 
only  over  the  few  months  required  for  the  establishment  of  menstrua- 


THE  PHYSIOLOGICAL  PERIODS  IN  THE  LIFE  OF   WOMAN.     27 

tion,  but  as  including  the  time  necessary  for  full  physical  develop- 
ment. During. this  period  the  energy  of  the  girl  is  taxed  by  the 
rapidity  of  sexual  development,  by  the  great  liability  to  circulatory 
disturbances,  by  the  physical  and  mental  strain  of  education,  and  by 
the  conventionalities  of  society.  The  necessity,  therefore,  for  great 
care  is  apparent.  Nutritious  and  simple  diet,  frequent  rest,  moderate 
amusements,  and  adequate  exercise  are  essential.  Study,  especially 
during  menstruation,  should  never  be  pressed  to  the  point  of  fatigue. 
Inasmuch  as  passional  life  now  begins,  and  the  whole  nervous  organiza- 
tion is  therefore  subject  to  new  impulses  and  requirements,  books 
and  associates  should  be  selected  carefully,  and  whatever  may  unduly 
excite  the  emotions  should  be  excluded.  Errors  committed  now  may 
have  grave  consequences,  such  as  malnutrition,  psychoses,  sterility, 
menstrual  and  other  functional  disorders,  and  may  make  the  woman  a 

Figure  4. 


Ovary  and  Fallopian  tube,  from  a  woman  forty-one  years  of  age.    Natural  size.    Atrophic 
processes  and  consequent  decrease  in  size  of  the  ovary  and  tube  already  begun. 


hopeless  invalid.     For  reasons  already  given,  one  of  the  most  serious 
errors  is  premature  marriage. 

Education. — According  to  prevailing  ideas,  the  higher  education 
and  civilization  strongly  tend  to  check  and  pervert  the  development 
of  woman,  to  cause  numerous  weaknesses,  to  increase  the  burdens  and 
dangers  of  maternity,  and  to  lessen  the  vigor  of  the  offspring.  We 
are  told  that  the  republic  is  in  danger  from  deterioration  of  the  edu- 
cated classes.  These  pessimistic  forebodings  have  arisen  and  gained 
headway  rather  upon  assertion  than  upon  known  fact.  The  ability  of 
the  squaw  immediately  after  parturition  to  resume  the  march  is  urged 
often  as  an  argument  against  the  higher  education  of  woman  ;  on  the 
other  hand,  observation  among  Indian  women  has  shown  abun- 
dantly that  want  of  care,  during  and  after  labor,  is  the  constant  cause 
of  complete  prolapse  of  the  uterus,  vagina,  and  bladder,  and  of  num- 
erous other  diseases  which  are  relatively  much  more  prevalent  among 
them  than  among  the  higher  classes  of  civilized  women.  The  edu- 
cated woman  could  "  resume  the  march  "  if  it  were  necessary  ;  history 


28  GENERAL  PRINCIPLES. 

has  shown  many  heroic  examples  ;  but  education  has  taught  her  that 
this  is  unsafe.  The  savage  woman  looks  old  and  withered  at  thirty ; 
the  civilized  woman  preserves  something  of  youth  until  after  the 
age  of  fifty.  The  highest  civilization  if  carried  forward  under  proper 
conditions  should  more  than  offset  any  deteriorating  influence  which 
may  come  of  a  departure  from  primitive  conditions ;  it  should  give  to 
the  civilized  race  a  vitality  much  greater  than  that  of  the  savage,  and 
to  the  civilized  woman  a  power  of  resistance  which,  if  properly  trained 
and  directed,  will  enable  her  to  endure  and  to  survive  many  trials  to 
which  a  savage  woman  would  succumb.  To  make  the  deteriora- 
tion of  woman,  and  through  this  the  enfeeblement  of  the  race,  a  price 
which  must  be  paid  for  the  higher  education  and  civilization,  would 
be  seemingly  to  reverse  the  law  of  evolution  and  to  put  in  its  place  a 
law  of  the  survival  of  the  unfittest. 

The  Goitre  of  Puberty. — The  changes  of  puberty  are  in  some 
cases  associated  with  an  enlargement  of  the  thyroid  gland,  called 
goitre,  a  condition  that  often  disappears  with  the  complete  establish- 
ment of  menstruation.  In  early  goitre  the  glands  are  soft  and  almost 
fluctuating.  If  the  enlargement  persists,  the  tumor  becomes  fibrous, 
hard,  and  intractable.  Such  enlargement  may  be  treated  in  the  early 
stage  with  inunctions  of  biniodide  of  mercury,  30  grains  to  the  ounce. 
This  should  be  applied  daily  for  periods  of  four  or  five  days.  When  the 
skin  becomes  irritated  the  application  should  be  interrupted  until  the 
irritation  has  subsided,  and  then  resumed.  These  inunctions,  together 
with  the  continued  use  of  calomel  or  the  bichloride  of  mercury,  in 
minute  doses,  will  result  sometimes  in  rather  prompt  disappearance  of 
the  swelling.  The  thyroid  extract  in  doses  of  2  grains  three  times 
a  day  will  in  some  cases  effect  a  rapid  cure ;  if  distinct  improvement 
is  not  apparent  in  two  or  three  weeks,  the  drug  should  be  discontinued  ; 
in  any  case  the  use  of  it  should  be  guarded,  and  the  dose  regulated  if 
necessary  to  an  amount  that  will  not  cause  disagreeable  nervous 
symptoms. 

MATURITY. 

The  time  of  sexual  maturity  extends  from  the  end  of  puberty  to 
about  the  forty-second  year,  and  under  normal  conditions  is  a  rela- 
tively healthy  period.  Unlike  puberty  and  the  menopause,  it  is 
comparatively  free  from  neuroses  and  psychoses,  except  those  con- 
nected with  pregnancy.  •  The  woman  is  subject,  however,  to  the 
burdens  and  accidents  of  menstruation,  ovulation,  pregnancy,  mater- 
nity, physical  and  mental  overstrain,  and  to  the  dangers  of  puerperal 
and  other  infection,  among  which  especially  may  be  mentioned  gonor- 
rhea— a  potent  cause  of  vulvo-vaginitis,  metritis,  salpingitis,  ovaritis, 
peritonitis,  cystitis,  pyelitis,  and  nephritis. 

During  this  period  the  non-malignant  neoplasms  more  frequently, 
and  the  malignant  neoplasms  less  frequently,  endanger  life  and  health. 


THE  PHYSIOLOGICAL  PERIODS  IN  THE  LIFE  OF  WOMAN.      29 

THE  MENOPAUSE. 

The  menopause,  sometimes  called  the  climacteric,  sometimes  the 
change  of  life,  is  the  second  critical  period.  It  usually  takes  place 
between  the  ages  of  forty  and  fifty ;  the  occurrence  of  this  crisis 
before  the  fortieth  or  after  the  fifty-second  year  is  abnormal ;  it  con- 
tinues from  three  to  five  years.  Pathological  causes  more  or  less 
recognizable,  and  the  influence  of  heredity,  may  shorten  or  lengthen 
it.  In  very  cold  climates  both  puberty  and  the  menopause  are  delayed. 
The  opposite  is  true  in  warm  climates. 

The  Anatomical  and  Physiological  Basis  of  the  Menopause 
is  atrophy  and  cessation  of  function.     This  critical  period  is  charac- 

FlGUEE  5. 


fltrn^w^^^'f  L^'''®  °^  ^l^'^l'-  Fallopian  tube,  and  uterus  of  a  woman  seventy  years  of  age     Senile 
foX^uVt^^o'^hXo'f^^^^e'LS'eX"^'^^"    Rudixnentary  ovary  and  tu^bl    Uterus^troSl 

terized  by  the  following  senile  changes  in  all  the  reproductive  oro-ans 
some  of  which  are  pathological.  *      ' 

1.  Senile  changes  in  the  ovary : 

a.  Atrophy,  induration,  and  shrinkage  to  rudimentary  size. 
h.  Disappearance  of  Graafian  follicles, 
c.  Cessation  of  function. 

2.  Senile  changes  in  the  Fallopian  tubes  : 

a.  Shortening  and  narrowing ;  often  complete  obliteration  of 

lumen. 
h.  Destruction  of  epithelial  elements. 

3.  Senile  changes  in  the  uterus  : 

a.  Atrophy  of   entire  organ  to  rudimentary  size;    may  be 

reduced  to  a  hard,  wedge-shaped  body,  one-fourth  size 
of  mature  organ. 

b.  Muscular  and  glandular  elements  become  rudimentary. 


30  GENERAL  PRINCIPLES. 

c.  Canal  may  close  at  internal  os,  or  external  os,  or  become 

obliterated  throughout. 

d.  Secretions  may  be  locked  up  by  obliteration  of  the  cervical 

canal  producing  pyometra  or  hydrometra. 

e.  A'aginal  portion  may  disappear,  making  the  upper  part  of 

the  vagina  continuous  with  the  uterine  canal. 

4.  Senile  changes  in  the  vagina  : 

a.  Shortening,  narrowing,  and  loss  of  elasticity. 

b.  Loss  of  pavement  epithelium  and  substitution  of  a  hard 

surface  containing  more  or  less  cicatricial  tissue. 

c.  Contraction  of  introitus  vaginae. 

5.  Senile  changes  in  the  vulva:  _  _ 

a.  Same  as  in  vagina — great  contraction  and  loss  of  elasticity. 
6.  Destruction  or  impairment    of  vulvovaginal  glands   and 
vulvar  follicles. 

c.  Cutaneous  surface  dry  and  scaly. 

d.  Hair  on  mons  veneris  may  turn  gray. 

6.  Senile  changes  in  the  mammce  : 

a.  Loss  of  glandular  elements  and  cessation  of  function. 

b.  Atrophy  and  shrinkage ;    sometimes   the  atrophic  loss  is 

made  up  or    more   than    made  up   by   the   deposition 

of  fat. 

The  Essential  Phenomenon  of  the  Menopause  is  permanent 

arrest  of  all  functions  peculiar  to  the  reproductive  organs.     It  is  the 

inversion  of  the  developmental  process  of  puberty.     It  marks  the  end 

of  active  sexual  life.      The   atrophic    changes  are  known  as   senile 

atrophy. 

The  Symptoms  of  the  Normal  Menopause  are  referable  to  two 
stages  :  a  stage  of  menstrual  irregularity  preceding  the  cessation  of  the 
menses,  and  a  post-cessation  stage  of  variable  systemic  disturbances. 
In  normal  or  nearly  normal  cases  the  menstrual  irregularities  and  the 
systemic  disturbances  are  slight.  The  woman  may  at  times  be  unusu- 
allv  capricious  and  emotional ;  yet  she  passes  through  this  physiologi- 
cal crisis  with  only  a  few  minor  perturbations,  such  as  the  character- 
istic vasomotor  flushes,  perspiration,  vertigo,  somnolence,  numbness, 
and  faintness.  The  menstrual  function  ceases  as  it  began,  with  marked 
svmptnms  referable  to  the  nervous  system. 

'  Symptoms  of  Abnormal  Menopause.— Irritability,  apprehen- 
siveness,  hvsteria,  melancholia,  and  other  psychic  disturbances,  more 
or  less  exaggerated,  are  common  in  the  abnormal  cases.  The  flow 
mav  becomT  continuous ;  it  may  become  so  excessive  as  almost  to 
amount  to  dangerous  hemorrhage  ;  or  life  may  be  jeopardized  by  a 
slow,  continuous  drain.  There  is  an  increased  tendency  to  malignant 
disease  of  the  uterus  and  breasts  during  this  period,  the  excessive  fear 
of  which  mav  almost  amount  to  a  symptom  of  melancholia. 

The  menopause  often  cures  pelvic  disease  ;  this  is  because  path- 
ologv  is  phvsiology  modified  by  disease,  and  because  atrophic  changes 
when  they  arrest  phvsiological  processes  may  also  at  the  sanie^  time 
put  an  end  to  pathological  processes.  Especially  is  this  true  if  the 
pathological  processes  have  depended  upon  the  functional  activity  of 


THE  PHYSIOLOGICAL  PERIODS  IN  THE  LIFE  OF   W03IAN.      31 

the  organs  involved.  It  therefore  follows  that  a  woman  who  has 
suffered  for  years  from  chronic  uterine  or  ovarian  disease  may  now 
enter  upon  a  long  period  of  increased  vigor  and  robust  health.  It 
may,  however,  be  a  dangerous,  even  a  fatal  mistake  to  assume  that 
the  ills  occurring  at  this  time  of  life  properly  belong  to  the  meno- 
pause ;  that  they  need  give  no  anxiety  ;  that  they  will  disappear  with 
it ;  and  that  they  therefore  require  no  attention.  Although  such  a 
notion  prevails,  yet  some  of  the  most  grave  disorders  of  the  meno- 
pause are  consequent  upon  pathological  states  for  which  atrophv  of 
the  reproductive  organs  gives  no  relief.  Continuous  and  profuse 
hemorrhages  and  excessive  nervous  disturbances  are  matters  of  specially 
grave  solicitude,  and  since  the  one  may  indicate  malignant  disease  and 
the  other  may  tend  to  mental  derangement,  prompt  diagnosis  and 
energetic  treatment  may  be  imperative. 

SENILITY. 

The  period  of  senility  follows  the  menopause  and  continues  to  the 
end  of  life  ;  it  is  the  decline  of  life,  and  is  normally  a  period  of  repose. 
The  functions  of  the  reproductive  organs  having 'ceased,  the  organs 
have  little  physiological  significance.  "  The  special  disorders  and  dan- 
gers of  this  period,  such  as  malignant  growths,  senile  vulvovaginitis, 
and  senile  endometritis,  will  be  considered  in  the  proper  connec- 
tions. 


CHAPTEE    II. 

SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE. 
General   Considerations. 

Micro-organisms  are  clearly  the  cause  of  the  septic — that  is,  the 
so-called  iuflammatory — diseases  of  women.  The  millions  of  cocci 
found  on  microscopical  examination  of  a  single  drop  of  fluid  taken 
from  the  abdomen  of  a  case,  for  example,  of  septic  peritonitis  show  the 
tremendous  developmental  power  of  micro-organisms.  It  is  crim- 
inal for  a  physician  to  go  immediately  from  a  case  of  virulent  infec- 
tion to  visit  other  patients  without  any  disinfection  except  the  ordi- 
nary washing.  It  is  usually  unsafe  to  go  after  the  ordinary  disinfec- 
tion. It  is  desirable,  and  may  be  necessary,  that  the  disinfection  be 
not  only  most  painstaking,  but  even  repeated  on  two  or  three  consecu- 
tive days.  The  reader  is  referred  to  the  paragraph  on  the  use  of  rub- 
ber gloves  in  another  part  of  this  chapter. 

Septic  infection  formerly  caused  an  appalling  mortality  in  the  major 
gynecological  operations  and  made  the  minor  manipulations  extra 
perilous.  The  fear  of  infection  was  so  great  that  when  the  malady 
was  neither  fatal  nor  very  disabling  the  practitioner  often  used  tem- 
porizing measures  however  unpromising,  to  the  exclusion  of  surgical 
measures  however  rational.  ISTow  the  application  of  the  aseptic  prin- 
ciple has  made  all  gynecological  procedures  relatively  safe. 

Sepsis  is  the  general  term  for  all  surgical  infections  of  microbic 
origin.  The  term  asepsis,  and  the  corresponding  adjective  aseptic,  are 
used  to  imply  the  absence  of  these  infections.  The  phenomena  of 
sepsis  are  due  doubtless  to  the  products  of  bacteria  more  than  to  the 
bacteria  themselves. 

The  genital  tract  of  the  newborn  is  sterile.  In  mature  life,  under 
normal  conditions,  the  cervix  and  corpus  uteri  and  Fallopian  tubes 
are  sterile,  but  the  vagina  contains  numerous  non-pathogenic  micro- 
organisms.    See  Chapter  XI. 

Forms  of  Infection. 

Septicaemia. — The  presence  of  infectious  microbes  in  the  circula- 
tion, together  with  the  chemical  action  of  their  products,  gives  rise  to 
the  condition  called  septiceemia. 

Toxaemia. — Certain  microbes  exist  locally  and  may  send  out  their 
products  through  the  circulation,  thereby  producing  septic  toxaemia. 
32 


PLATE  III 


«  n 

J?       "if      ,** 


<"- 


Bacillus  Coli  Communis. 


Gonoeoecus. 


h 


i«^.- 


/<       ^.' 


^ 


Streptococcus  Pyogenes. 


Bacillus  Tuberculosis. 


Pneumococcus. 


Staph  ylococcus. 


Magnified   lOOO  diameters. 


SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE.  33 

Saprsemia. — When  the  toxaemia  is  due  to  the  products  of  putre- 
factive bacteria,  it  often  is  called  saprsemia. 

Pyaemia. — AVhen  pus  emboli  are  carried  through  the  circulation 
from  a  focus  of  suppuration  to  set  up  other  foci  in  different  portions 
of  the  body,  the  condition  is  called  pysemia. 

The  above  terms  and  others  like  them,  although  widely  used,  are 
not  absolutely  definite.  An  appreciation  of  their  meaning,  however, 
is  essential  to  a  knowledge  of  modern  surgical  literature. 

Microbic  invasion  may  be  in  the  form  of  wound  infection  or  may 
occur  in  the  unbroken  cutaneous  and  mucous  structures. 

The  micro-organisms  most  common  in  gynecology  are  : 

Gonococcus  of  Neisser,  Bacillus  coli  communis, 

Staphylococcus  pyogenes  aureus,     Streptococcus  pyogenes, 
Staphylococcus  pyogenes  albus,       Bacillus  tuberculosis. 

Among  the  microbes  less  common  in  gynecology  are  : 
Bacillus  pyocyaneus,  Pneumococcus, 

Bacillus  typhosus,  Streptothrix  actinomyces, 

Bacillus  diphtheriae,  T^acillus  aerogenes  capsulatus. 

Gonococcus. — The  gonococcus  is  the  microbe  of  gonorrhoea  and 
is  invariably  present  in  the  urethral  discharge  in  gonorrhoea,  and  also 
in  other  parts  of  the  genital  tract  when  they  are  the  seat  of  gonor- 
rhoeal  infection.  A  most  striking  peculiarity  of  the  germ  is  the  power 
to  penetrate  and  intrench  itself  in  the  deeper  layers  beneath  the 
mucous  surfaces,  especially  in  glandular  structures.  It  may  also 
migrate  to  distant  organs,  having  been  found  in  the  joints  in  cases  of 
gonorrhoeal  rheumatism,  in  the  perspiration,  and  in  the  structures  of 
the  heart.  The  greatest  pathogenic  significance  of  the  germ  is  due  to 
the  destructive  action  which  it  exerts  upon  infected  organs.  It  does 
not  set  up  general  septicaemia,  but  rather  acts  locally,  and  is  very 
persistent  and  destructive  in  the  conjunctiva,  in  the  infantile  vagina, 
and  in  the  Fallopian  tubes  of  adults. 

Staphylococcus  Pyog-enes  Aureus  and  Albus. — Staphylo- 
coccus pyogenes  aureus  and  albus,  which  resemble  one  another  in 
form,  are  the  most  widely  distributed  and  most  common  causes  of 
suppuration.  The  former  is  found  in  almost  all  localized  abscesses 
and  in  various  other  pyogenic  conditions.  It  varies  in  pathogenic 
power  from  coiliparative  mildness  to  great  virulence.  The  latter  is 
less  virulent.  Both  varieties  often  are  associated  with  other  pyogenic 
microbes. 

Streptococcus  Pyogenes. — Streptococcus  pyogenes  is  one  of 
the  most  virulent,  fatal,  and  important  of  the  ])yogenic  microbes,  and 
is  especially  dangerous  as  a  cause  of  puerperal  and  traumatic  septi- 
caemia and  septic  peritonitis.  It  is  the  micro-organism  of  erysipelas. 
Unlike  the  gonococcus,  which  spreads  preferably  by  way  of  the  mucosa, 
this  germ  follows  the  lymph-vessels  and  blood-vessels. 

Bacillus  Coli  Communis. — Bacillus  coli  communis  is  a  normal 
mhabitant  of  the  intestine,  and  is  a  frequent  cause  of  peritonitis  fol- 
lowing intestinal  lesions  and  of  puerperal  infection  and  of  cystitis. 
3 


34  GENERAL  PRINCIPLES. 

Bacillus  Tuberculosis. — Bacillus  tuberculosis  has  been  found  in 
all  of  the  genito-urinary  organs  and  very  frequently  in  tuberculous 
peritonitis  and  salpingitis.  It  is  seldom  a  cause  of  traumatic  infec- 
tion, and  is  therefore  not  to  be  feared  as  a  factor  in  surgery.  On  the 
contrary,  surgical  operations  are  said  to  have  a  decided  inhibitory 
eifect  on  the  progress  of  tuberculous  peritonitis,  the  disease  having  in 
some  cases  disappeared  after  simple  exploratory  incision.  It  is,  how- 
ever, doubtful  whether  such  a  result  should  be  regarded  as  post  hoc  or 
propter  hoc. 

ASEPTIC  TECHNIQUE. 

General  Considerations. 

The  causation  and  course  of  infection"  necessarily  depend  upon  the 
source,  virulence,  and  number  of  the  organisms  ;  upon  the  volume 
and  nature  of  their  products — that  is,  the  toxins  ;  and  upon  such  local 
conditions  as  the  presence  of  foreign  bodies,  pathological  secretions, 
bruised,  congested,  and  necrotic  tissues,  and  dead  spaces.  In  the  vast 
majority  of  cases  infection  is  introduced  by  the  hand  of  the  surgeon 
or  by  instruments  and  other  appliances,  and  when  so  introduced  from 
without  it  is  called  hetero-infection.  Auto-infection  is  caused  by 
organisms  existing  in  the  patient.  Some  bacteria  reach  the  wound 
through  the  air,  but  they  are  usually  not  virulent,  and  are  therefore 
not  dangerous. 

Fortunately,  the  fluids  and  living  tissues  of  the  body  have  germi- 
cidal power,  and  consequently  oifer  a  degree  of  resistance  to  bacterial 
invasion.  Many  germs,  therefore,  which  in  artificial  media  would 
flourish,  may  become  inert  when  exposed  to  the  resistance  of  living 
tissue.  Since  this  resistance  is  often  inadequate,  it  becomes  necessary 
so  far  as  possible  to  exclude  the  organisms  from  the  field  of  operation 
by  aseptic  measures,  or  to  destroy  them  by  antiseptic  agents.  It  is 
clearly  important  that  the  power  of  tissues  to  resist  organisms  be 
not  impaired  by  the  too  free  use  of  chemical  antiseptics  or  mechanical 
agents. 

The  mere  acceptance  of  the  aseptic  idea  without  a  thorough  and 
systematic  application  of  it,  not  only  in  major  operations,  but  even  in 
simple  manipulations,  is  inadequate.  Efficient  technique  is  essential, 
and  is  the  outgrowth  of  a  comprehensive  grasp  and  an  intelligent 
appreciation  of  the  causes,  prevention,  and  remedies  of  septic  infec- 
tion. It  requires,  above  all,  the  development  of  what  has  aptly  been 
called  the  aseptic  conscience. 

Asepsis  is  the  absence  of  infectious  bacteria.  Strictly  speaking, 
this  may  be  an  ideal  condition,  since  it  is  not  always  fully  realized  ; 
but  it  is  usually  possiV)le  to  limit  the  number  of  bacteria  to  a  safe 
minimum,  or  to  render  them  harmless  by  means  of  drugs,  chemi- 
cals, and  other  agents.  Such  agents  are  called  antiseptics.  When 
the  antiseptic  has  the  power  to  destroy  germs,  it  often  is  called  a 
germicide. 

Asepsis  involves  a  great  number  of  details  variable  and  difiicult 
to  anticipate,     A  complete  description  is  impossible  and  unnecessary. 


SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE.  35 

Once  grasp  the  great  principle  of  asepsis,  and  the  subordinate  details, 
otherwise  complex,  become  simple.  The  intelligent  operator,  for  ex- 
ample, who  knows  that  septic  infection  is  the  result  of  contact,  need 
not  be  told  that  during  an  operation  he  must  keep  his  hand  off  from 
whatever  is  not  sterile.  The  danger  of  sepsis  is  in  a  measure  propor- 
tionate to  the  length  of  the  operation,  to  the  exposure  of  the  wound 
or  cavity,  and  to  the  extent  of  the  traumatism.  It  follows,  therefore, 
that  an  operation  sliould  be  tinished  as  rapidly  and  with  as  little  oper- 
ating as  possible.  At  the  same  time,  the  slow  operator,  if  gentle  in 
his  movements,  is  less  dangerous  than  one  who  is  rapid  and  violent. 

Therapeutic  Use  of  Antiseptics. 

The  therapeutic  use  of  antiseptics  is  indicated  when  infection  actu- 
ally has  occurred.  Then  the  field  of  infection,  if  local,  may  be 
opened  and  disinfected  or  drained ;  if  the  infection  is  systemic,  the 
internal  use  of  antiseptic  drugs  may  be  indicated.  When  there  is  no 
infection,  and  the  use  of  antiseptic  drugs  is  therefore  prophylactic, 
they  should  be  used  but  sparingly,  if  at  all,  and  not  in  contact  with 
the  wound.  This  is  because  they  have  injurious  properties  which 
may  give  rise  to  dangerous,  even  fatal,  results.  The  use  of  these 
drugs  is  to  secure  surgical  cleanliness,  as  soap  is  used  to  secure 
aesthetic  cleanliness ;  and,  the  object  having  been  attained,  they  should 
be  washed  off  with  sterile  water  from  the  hands  and  instruments 
before  these  are  brought  in  contact  with  the  patient. 

Prophylactic  Use  of  Antiseptics. 

The  object  of  the  prophylactic  use  of  antiseptics  is  asepsis.  Before 
any  operation  or  manipulation  the  operator's  hands,  instruments  and 
other  appliances,  and  the  field  of  operation  or  manipulation  should 
be  rendered  surgically  clean  and  so  maintained  throughout^i/ig 
prophylactic  use  of  antiseptics  is  an  antiseptic  procedure  to  an  aseptic 
result. 

Antiseptic  Agents. — Among  the  antiseptics  in  most  common  use 
are  : 

Heat,  ■  Mercuric  bichloride, 

Soap,  .  Formalin, 

Carbolic  acid,  Alcohol. 

Heat. — The  actual  flame  and  the  hot-air  sterilizers  have  been  dis- 
carded for  the  most  part  in  gynecological  practice.  Moist  heat  is 
employed  in  the  form  of  boiled  water  and  of  steam. 

Sterilization  "by  Boiling. — Absolute  sterilization  for  bacteriological 
work  requires  boiling  for  thirty  minutes  on  three  consecutive  days  ; 
but  for  surgical  purposes  one  boiling  for  thirty  minutes  is  ample. 
Ordinary  pathogenic  microbes  are  destroyed  in  a  much  shorter  time. 

Sterilization  by  Steam  is  efficient,  available,  and  ^\  idely  applicable. 
Everything  connected  w'ith  an  operation  that  is  not  injured  by  heat 
may  be  made  aseptic  by  this  means.     For  this   purpose,  numerous 


36  GENERAL  PRINCIPLES. 

steam  sterilizers  have  been  devised,  that  of  Arnold  being  most  widely 
used.  It  contains  a  chamber  for  the  articles  to  be  sterilized.  The 
steam  displaces  the  air  from  this  chamber  and  coming  in  contact  with 
the  instruments,  ligatures,  towels,  gowns,  aprons,  dressings,  and  other 
articles,  renders  them  sterile,  or  at  least  practically  safe  for  surgical 
purposes,  in  about  sixty  minutes.  The  Boeckmann  steam  sterilizer, 
which  accomplishes  so-called  "  over-steam  sterilization,"  is  possibly 
more  effective  than  the  "  under-steam  "  sterilizers  of  Arnold  and  others. 
The  Boeckmann  sterilizer  has  the  advantage  of  not  wetting  the  dress- 
ings very  much,  and  is  provided  with  means  of  drying  them  before 
they  are  taken  out.  Steam  sterilization  repeated  for  thirty  minutes  on 
three  consecutive  days,  insures  the  final  destruction  of  any  spores 
that  might  otherwise  survive  the  first  exposure  and  germinate  the 
next  day. 

Soap,  although  not  a  strong  germicide,  is,  perhaps,  the  most  valu- 
able of  all  antiseptics.  It  is  used  for  cleansing  instruments,  cloth- 
ing, and  other  things  needed  in  connection  with  operations,  and  for 
washing  the  skin  of  the  patient  and  operator,  but  more  especially  for 
scrubbing  the  hands  and  arms  of  the  surgeon  and  his  assistants.  The 
familiar  sapo  viridis,  usually  called  green  soap,  is  the  variety  in  gen- 
eral use. 

Carbolic  Acid  is  a  chemical  antiseptic  of  great  power.  It  also  has 
the  highest  germicidal  and  deodorant  properties,  and  has  been  used 
more  freely  and  generally  than  any  other  antiseptic ;  but  it  has  prop- 
erties that  render  it  dangerous  for  the  patient  and  inconvenient  for 
the  operator.  It  corrodes  instruments,  irritates  the  skin,  and  by  its 
local  anaesthetic  properties  impairs  the  tactile  sense.  The  use  of  this 
drug  is  limited  now  to  the  disinfection  of  very  small  areas  of  local 
infection,  where  the  quantity  used  is  not  sufficient  to  cause  systemic 
poisoning,  even  though  the  acid  be  used  in  full  strength.  The  danger 
of  washing  out  septic  cavities  with  1,  2,  3,  or  5  per  cent,  solutions  is, 
generally  speaking,  prohibitory  ;  for  example,  profound  shock  repeat- 
edly has  followed  the  introduction  of  weak  solutions  into  the  rectum. 
It  is  soluble  in  hot  water  to  the  amount  of  5  per  cent.,  and  may  be 
rendered  much  more  soluble  by  the  addition  of  10  per  cent,  of 
glycerin. 

Mercuric  Bichloride,  like  carbolic  acid,  is  a  germicide  of  consid- 
erable power,  but  is  dangerous  if  brought  freely  into  contact  with  the 
patient.  It  may  be  used  for  disinfecting  the  hands  after  prolonged 
scrubbing,  for  the  sterilization  of  surgical  dressings,  and  for  solutions 
in  which  ligatures  and  sponges  may  be  kept.  The  drug,  however, 
should  be  washed  out  of  the  sponges  with  sterilized  water  before  they 
are  used.  Irrigation  of  the  bladder  with  a  solution  as  weak  as 
1  :  10,000  has  been  followed  by  most  violent  exfoliative  cystitis. 
It  should  never  be  used  in  the  urinary  system. 

Sodium  Carbonate. — Common  washing-soda  is  an  active  germi- 
cide when  used  in  a  1  per  cent,  solution  with  water,  but  it  does  not 
become  active  until  the  solution  has  been  raised  to  the  boiling-point ; 
then  sterilization  is  much  more  rapid  than  in  plain  boiling  water. 
The  boiling  solution  is  said  to  dissolve  the  capsule  of  the  germ  and  to 


SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE.  37 

destroy  it  in  five  minutes.     This  form  of  sterilization  is  suited  best  to 
instruments  and  other  appliances  that  are  not  injured  by  heat. 

Other  antiseptics,  such  as  formalin,  alcohol,  potassium  permangan- 
ate, oxalic  acid,  sulphuric  ether,  essential  oils,  turpentine,  boric  acid, 
and  nosophene,  are  useful  in  their  places  and  will  be  considered  later. 
Iodoform  may  be  rejected  because  of  its  poisonous  properties  and 
offensive  odor,  which  may  produce  protracted  nausea  and  vomiting. 

Hospital  Sterilizer. 

The  High-pressure  Steam  Sterilizer  for  Hospital  Use. — This 
sterilizer  is  almost  indispensable  in  hospitals  where  it  is  necessary 
to  sterilize  rapidly  large  quantities  of  dressings  and  other  appliances; 
but  is  too  complicated  and  usually  too  expensive  for  general  use  in 
private  practice ;  it  consists  of  a  large  circular  chamber  in  which 
the  articles  to  be  sterilized  are  placed  and  subjected  in  vacuo  to  high- 
pressure  steam.  The  creation  of  a  vacuum  before  admitting  the 
steam  insures  greater  thoroughness  in  sterilization.  This  sterilizer 
is  furnished  in  different  sizes,  the  diameter  varying  from  fourteen  to 
eighteen  inches  and  the  length  from  twenty-two  to  thirty  inches. 

Instruments,  Pouches,  Bags,  and  Cases. 

The  conventional  leather  instrument-pouch  is  a  prolific  incubator 
of  disease,  and  therefore  must  give  place  to  the  aseptic  pouch  of 
some  washable  fabric  which  may  be  sterilized  by  boiling  and  changed 
frequently.  Figure  6  shows  the  instrument-pouch  B  unrolled  and  C 
rolled  and  tied.     Figure  6  A  shows  an  ordinary  instrument-case. 

The  leather  instrument-bag  is  certain  to  become  unclean,  and  is 
therefore  dangerous.  The  canvas-covered  telescope  valise  is  inexpen- 
sive, practical,  and  easily  cleaned. 

Instrument-case,  Low-pressure  Sterilizers,  Sponge-basins,  and 
Trays  combined,  for  Use  in  Private  Practice. 

The  apparatus  shown  in  Figures  6,  7,.  and  8  is  designed  to  lighten 
the  burden  and  add  to  the  safety  of  surgical  work  in  private  houses, 
especially  in  the  country.  From  a  satisfactory  experience  of  several 
years  the  writer  offers  it  in  place  of  the  septic  instrument-bags, 
the  conventional  sterilizer,  the  cumbersome  trays  and  sponge-basins 
which  make  up  the  usual  impedimenta  of  surgical  practice  away 
from  hospitals.  The  apparatus  fulfils  the  requirements,  first,  of  an 
aseptic  instrument-case;  second,  of  a  steam  sterilizer;  third,  of 
instrument-trays  and  sponge-basins.  It  consists  of  two  rectangular 
sterilizers  made  of  copper,  nickel-plated,  in  which  may  be  packed  all 
instruments  and  other  appliances  requisite  fi)r  an  abdominal  section  or 
for  any  other  ordinary  surgical  operation.  The  component  parts  may 
be  used  separately  as  pans,  sponge-basins,  and  trays.  The  whole 
outfit,  enclosed  in  a  telescope  valise,  is  sixteen  inches  long,  nine  inches 
wide,  twelve  inches  high,  and   when  packed  ready  for  an  operation 


38 


GENERAL  PRINCIPLES. 

FlGUKE   6. 


A,  ordinary  instrument-case  ;  B,  washable  instrument  pouch,  unrolled  :  C,  pouch  rolled  and 
tied ;  D  contains  combination  instrument-case,  sterilizers,  sponge-basins,  and  trays,  packed  and 
ready  to  be  taken  to  an  operation. 

Figure  7. 


Metallic  instrument-cases  removed  from  telescope-case  and  transformed  into  two  sterilizers 

under  steam. 

Figure  8. 


The  several  part  of  the  combination  instrument-cases  being-  used  as  sponge-basins,  pans, 

and  trays 

weighs  about  twenty-five  pounds.     Figure  6,  D.     This  case  contains 
a  complete   set    of   instruments,  towels,  sponges,  ligatures,  suitings, 


SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE.  39 

dressings,  aprons,  nail-brushes,  sterilized  green  soap,  ether,  chloro- 
form, alcohol,  antiseptic  drugs,  rubber  sheet,  douche-bag,  etc.  The 
equipment  is  adapted  for  work  anywhere.  It  especially  solves  the 
problem  of  aseptic  surgery  outside  of  hospitals,  whether  at  the  house 
of  prince  or  pauper. 

Figure  7  represents  the  two  rectangular  copper  boxes  as  they 
appear  under  steam  when  used  as  sterilizers.  Observe  that  each 
sterilizer  is  supplied  with  four  legs,  which  may  be  folded  against 
the  sides  of  the  box  when  the  box  is  not  in  use  as  a  sterilizer.  Each 
box  contains  two  gauze-wire  trays,  as  shown  through  the  broken  side 
of  the  sterilizer  in  the  right-hand  cut  of  Figure  7.  The  lo\ver  tray  is 
one  inch  above  the  bottom  of  the  sterilizer,  and  contains  instru- 
ments. The  upper  tray,  resting  upon  the  lower,  contains  towels, 
dressings,  ligatures,  etc.  The  space  of  one  inch  between  the 
bottom  of  the  lower  tray  and  the  bottom  of  the  sterilizer — i.  e., 
below  the  line  A-A,  Figure  7 — is  filled  with  sterilized  water. 
The  small  trays,  B  and  B,  are  filled  with  burning  alcohol.  These 
trays  are  set  upon  saucers  to  prevent  burning  the  table-top. 
The  burning  alcohol  converts  the  water  into  steam,  Avhich  sterilizes 
the  contents  of  the  wire-gauze  trays.  One  of  the  two  detachable 
handles  resting  on  the  table  between  the  two  trays  may  be  used  to  put 
out  the  flame  by  lifting  the  small  alcohol-tray  in  contact  with  the 
bottom  of  the  sterilizer.  These  detachable  handles  are  designed  also 
for  use  in  separating  the  different  parts  of  the  sterilizers  after  the 
sterilization  is  complete. 

Finally,  the  several  parts  of  this  apparatus  may  be  utilized  as 
sponge-basins,  pans,  and  trays.  Figure  8,  The  two  large  copper  boxes 
become  sponge-basins,  X,  X.  The  two  top  covers  become  trays,  Y, 
Y,  holding  sterilized  water,  inside  of  which  two  of  the  gauze-wire 
trays  containing  the  instruments  are  placed.  The  gauze-trays  may  be 
lifted  out  by  the  detachable  handles  and  placed  in  the  covers  without 
han;lling  the  sterilized  instruments. 

The  other  two  gauze-trays  to  the  left  of  the  sponge-basins  (Figure 
8)  hold  the  towels,  gauze,  sponges,  dressings,  and  other  things  which 
have  been  sterilized  in  them.  The  two  small,  square,  shallow  cups 
which  contained  the  alcohol  in  Figure  7  now  become  trays  for  needles, 
ligatures,  and  other  small  appliances.  Figure  8,  B  and  B.  Observe 
that  this  sterilizer  is  quite  as  well  adapted  for  sterilization  by  boiling 
water  as  by  steam.  After  the  apparatus  has  been  under  steam  for 
thirty  minutes,  especially  if  this  process  has  been  repeated  three  times 
on  consecutive  days,  not  only  the  contents,  but  also  the  various  parts 
which  are  to  be  used  as  sponge-basins  and  trays,  are  sterilized  thor- 
oughly. Each  member  of  the  apparatus  is  supplied  witli  one  or  more 
slots  or  rings,  into  which  fit  the  detachable  metallic  handles  already 
mentioned.  These  handles  are  useful  to  separate  the  sterilizer  into  its 
several  parts  while  hot,  and  to  avoid  unnecessary  handling.  After  an 
operation,  even  upon  a  septic  case,  all  the  parts  of  the  apparatus  may 
be  washed  and  then  sterilized  by  boiling  in  a  large  wash-boiler.  The 
boiling  water  should  contain  2  per  Cent,  of  sodium  carbonate. 


40  GENERAL  PRINCIPLES. 

Preparation  for  an  Aseptic  Abdominal  Section. 

Asepsis  necessitates  a  number  of  antiseptic  procedures  all  looking 
to  an  aseptic  result.  The  scrupulous  preparations  about  to  be  out- 
lined for  major  operations  are  not  intended  to  imply  that  equal  care  is 
unnecessary  for  minor  operations,  because  the  latter  are  by  no  means 
free  from  clanger  of  fatal  sepsis,  and  because  a  performance  seemingly 
of  minor  importance  in  the  beginning  may  end,  accidentally  or  pur- 
posely, in  opening  the  abdomen  or  in  some  other  capital  procedure. 
Traumatic  infection  of  the  peritoneum  involves  the  gravest  conse- 
quences, hence  the  need  of  extreme  precautions  in  technique ;  and 
since  the  greater  may  include  the  lesser,  the  same  technique  will  suffice 
for  the  minor  procedures. 

The  recklessness  which  results  in  the  unnecessary  removal  of 
pelvic  organs  seldom  escapes  criticism.  The  recklessness  w'hich  re- 
sults in  the  unnecessary  introduction  of  sepsis  into  the  peritoneum  is 
often  passed  by  without  comment.  The  danger  to  life,  however,  is 
determined  less  by  what  the  surgeon  taJces  out  than  by  what  he  puts 
in.  The  development  of  sepsis  requires  two  conditions  :  first,  patho- 
genic bacteria  must  be  present ;  second,  the  way  must  be  opened  for 
them  to  enter.  Experiment  has  show^n  that  they  may  be  transmitted 
even  through  the  unbroken  skin  or  mucous  membrane,  but  that  trau- 
matism makes  an  open  door.  Pathogenic  bacteria  have  their  source, 
first,  in  the  operator  or  his  assistants ;  second,  in  the  instruments  and 
other  appliances ;  third,  in  the  patient.  The  antiseptic  procedures  to 
an  aseptic  result  therefore  must  be  these : 

1.  Preparation  of  the  operator  and  his  assistants. 

2.  Preparation  of  the  instruments,  sponges,  dressings,  and  other 

appliances. 

3.  Preparation  of  the  patient. 

1.  Preparation  of  the  Operator  and  His  Assistants. — Health  of 
the  Operator. — The  operator  and  assistants  should  be  in  good  health, 
and,  since  the  breath  may  be  a  medium  of  infection,  they  should 
especially  be  free  from  nasal  catarrh  and  coryza.  Disorders  of  nutri- 
tion which  involve  deficient  elimination  through  the  bowels  and  kid- 
neys may  throw  that  function  upon  the  lungs,  and  cause  the  breath  to 
be  loaded  with  fetid  products,  an  undoubted  source  of  infection.  The 
bacteria  of  saliva  may  be  most  infectious  ;  hence  ininecessary  talking 
over  the  field  of  operation  is  objectionable,  for  small  particles  of  saliva 
and  its  bacteria  may  reach  the  wound.  Experience  has  shown  that 
an  orator  in  speaking  may  throw  particles  of  saliva  thirty  feet  into  the 
audience.  The  necessity,  therefore,  of  protecting  wounds  and  open 
cavities,  by  means  of  a  mask,  against  the  germ-laden  breath  of  the 
operator  and  assistant  is  apparent  and  urgent.  A  mask  of  ten 
layers  of  gauze  tied  over  mouth  and  nose  is  effective ;  fewer  layers 
have  been" found  inadequate.  A  striking  case  in  point  is  the  follow- 
ing :  A  colleague,  while  operating  for  varicose  vein  of  the  leg,  noticed 
a  slight  particle  of  saliva  thrown  into  the  wound  from  the  mouth  of 
his  assistant,  whose  saliva,  on  examination,  was  proved  to  contain 
streptococci.  The  patient,  despite  most  careful  antiseptic  care,  died 
of  streptococcus  infection. 


•  SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE.  41 

The  daily  bath  is  an  important  part  of  the  routine  of  aseptic  sur- 
gery. Special  clothing  made  of  washable  material  is  desirable ;  for 
women  the  usual  costume  of  the  trained  nurse,  and  for  men  trousers 
and  shirts  or  short  coats.  Special  clothing  for  operation  has  a  three- 
fold advantage.  It  protects  the  operator  from  taking  cold  after  leav- 
ing the  operating-room  in  his  ordinary  clothing,  which,  if  worn 
during  the  operation,  might  be  wet  with  perspiration.  It  saves  the 
ordinary  clothing  from  contamination  when  the  operation  is  upon  a 
septic  case.  It  is,  above  all,  an  antiseptic  measure  in  the  interest  of 
the  patient. 

Sterilization  of  the  Hands  and  Arms. — Formerly  the  extreme 
mortality  of  abdominal  sections  was  due  in  great  part  to  direct 
infection  from  the  hand  of  the  operator.  To  wash  the  hands  rapidly 
in  soap  and  water  and  then  to  dip  them  in  some  antiseptic  solution,  a 
not  uncommon  practice  even  now,  gives  little  protection  against  infec- 
tion. Absolute  sterilization  of  the  skin  without  injuring  it  is  ideal 
and  impossible.  Practical  asepsis,  however,  is  possible.  To  bring 
this  about  numerous  antiseptics  have  been  used  ;  by  antiseptics  are 
meant  antiseptic  drugs  and  antiseptic  measures.  Of  these,  prolonged 
scrubbing  with  green  soap  sterilized  by  heat  and  with  hot  water  is 
the  most  effective.  A  mixture  of  alcohol  and  sulphuric  ether,  which 
have  germicidal  properties,  each  one  part,  with  four  parts  of  green 
soap,  makes  a  valuable  liquid  antiseptic  soap.  The  green  soap  should 
be  of  good  quality  and  previously  sterilized  by  heat.  Beat  one  pound 
of  this  soap  in  a  receptacle  with  two  ounces  of  alcohol  until  uniformly 
smooth.  Transfer  to  a  glass  bottle  of  at  least  three  pints  capacity 
and  add  two  ounces  of  ether.  Cork  well,  agitate,  and  set  aside  for 
two  hours.  Then  add,  with  thorough  shaking,  two  ounces  each  of 
ether  and  alcohol  previously  mixed.  The  scrubbing  of  the  hands 
and  forearms,  to  be  effective,  must  be  in  soap  and  water  as  hot  as  can 
be  borne  without  positive  discomfort.  The  heat  is  a  valuable  aid  in 
the  removal  of  dirt.  The  scrubbing  must  be  thorough  and  vigorous, 
and  prolonged  for  at  least  fifteen  minutes.  The  longer  the  scrubbing 
the  more  difficult  it  is  to  cultivate  bacteria  from  the  scrapings  of  the 
skin. 

Prolonged  Scrubbing  makes  the  hands  safe,  not  so  much  h\  the 
destruction  as  by  the  mechanical  removal  of  bacteria.  Thev  are 
removed  together  with  the  secretions  of  the  skin  and  other  foreign 
matter  upon  which  bacteria  flourish.  To  scrub  the  hands  and  fore- 
arms, always  use  a  very  large  brush,  preferably  without  handle.  The 
large  brush  is  indispensable  ;  it  cannot,  however,  be  made  to  reach 
those  strongholds  of  bacteria  so  often  overlooked  or  neglected,  the 
angles  between  the  fingers  ;  to  scrub  out  these  angles  thoroughly,  use 
a  brush  with  a  handle  of  ordinary  size,  but  do  not  attempt  to  scrub 
the  other  parts  of  the  hands  and  the  arms  with  such  a  brush  ;  it  is  too 
small.  Destroy  all  brushes  that  have  been  used  in  septic  cases. 
Brushes  not  in  actual  use  should  be  made  aseptic  and  kept  in  aseptic 
gauze  or  towels. 

Alcoholic  Solution  of  Mercuric  Bichloride. — After  scrubbing  ^ith 
green  soap  or  the   liquid  antiseptic   soap  just  mentioned,  wash  off  all 


42  GENERAL   PRINCIPLES. 

trace  of  soap  with  clean  water.  Then  wash  with  ]  :  .3000  sohition  of 
mercuric  bichhjride  in  70  per  cent.  alcohoL  Frequent  washing  of  the 
hands  and  arms  in  this  solution  as  often  as  they  become  dry  for  a 
period  of  ten  minutes  is  more  practical  and,  therefore,  more  likely  to 
be  carried  out  effectively  than  the  usual  soaking  for  an  equal  length 
of  time.  Aqueous  solutions  sterilize  less  surely  and  less  quickly  and, 
therefore,  are  unnecessary  for  hand  sterilization  if  this  alcoholic  solu- 
tion of  mercuric  bichloride  be  used. 

Rubber  Gloves. — Rubber  gloves  serve  as  protection  alike  to  the 
operator  and  the  patient,  and  in  all  abdominal  operations  should  be 
worn  by  all  persons  whose  hands  are  brought  into  relation  directly  or 
indirectly  with  the  field  of  operation.  After  an  operation  they  may 
be  sterilized  by  boiling,  and  used  again.  Only  two  plausible  objec- 
tions to  the  use  of  the  gloves  have  been  raised  :  first,  that  the  hands 
can  be  sterilized  adequately,  and  that  the  gloves  are  therefore  unneces- 
sary ;  second,  that  they  impede  the  operator  to  such  an  extent  as  to 
increase  rather  than  diminish  the  danger  of  the  operation.  The 
reason  for  the  first  objection  is  not  true  ;  but  if  it  were  true  that  the 
hands  can  be  sterilized  adequately,  it  by  no  means  follows  that  they 
always  will  be.  The  second  objection,  that  gloves  impede  the  operator 
to  any  considerable  degree,  can  be  urged  by  no  one  unless  he  would 
thereby  give  such  evidence  against  his  own  dexterity  as  will  raise  the 
question  of  his  fitness  for  surgical  work.  Gloves  may  be  dispensed 
with  in  exceptional  cases  when  very  rapid  work  is  of  vital  importance. 
The  use  of  the  gloves  should  in  no  respect  lead  to  relaxation  in  the 
sterilization  of  the  hands,  for  they  may  be  cut  or  punctured  during  an 
operation,  in  which  case,  however,  they  should  be  replaced  immediately 
by  fresh  ones. 

Sterilization  of  the  Nails,  Hair,  and  Beard. — Let  the  nails  be  cut 
short;  long  nails  retain  quantities  of  dirt  which  any  amount  of  scrub- 
bing may  fail  to  dislodge.  They  are  also  a  possible  cause  of  unneces- 
sary irritation,  not  to  say  traumatism,  and  may  therefore  be  both  the 
carriers  of  poison  and  the  instruments  for  its  inoculation.  The  shorter 
the  hair  the  less  dirt  will  there  be  to  fall  from  it  into  the  wound.  The 
hair  and  scalp  must  be  kept  clean  by  frequent  washing  and  brushing. 
The  long,  full  beard  is  an  unnecessary  source  of  danger  ;  the  less  beard 
the  better.  A  gauze  turban  about  the  operator's  head  guards  the 
wound  from  fine  particles  of  dirt  which  otherwise  might  fall  from  the 
hair ;  if  lirought  well  down  on  the  forehead,  the  turban  absorbs  per- 
spiration and  thereby  keeps  it  from  dropping  into  the  v/ound.  The 
operator's  forehead,  if  wet  with  perspiration,  may  be  kept  dry  by 
means  of  a  towel  in  the  hand  of  a  special  assistant. 

2.  Preparation  of  Instruments,  Sponges,  Dressings,  and  Other 
Appliances. — Sterilization  of  Instruments. — All  instruments  not  in- 
jured by  heat  may  be  sterilizedby  boiling  or  by  steam.  Sterilization  by 
boiling  takes  only  five  minutes  if  the  boiling  water  contains  1  per  cent, 
of  sodium  carbonate.  This  method  is  perfect  in  its  results,  even 
though  the  instruments  have  been  used  in  a  septic  case.  Boiling  in 
carbolic  acid  solution  is  no  more  efficient,  and  it  injures  the  instruments. 

Before  and  after  an  operation  instruments,  sponge-basins,  trays,  and 


SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE.  43 

other  appliances  may  be  washed  thoroughly  in  soap  and  water  to  re- 
move the  visible  dirt,  and  then  sterilized  by  boiling  in  a  large  wash- 
boiler.  A  good  way  is  to  sterilize  instruments  by  boiling  just  after 
using,  and  by  ste^m  just  before  using.  During  an  operation  the 
instruments  should  be  arranged  in  trays  and  covered,  not  with  anti- 
septic solutions,  but  with  sterilized  water. 

Sterilization  of  Water. — AVater  may  be  sterilized  by  boiling  for 
thirty  minutes.  If  not  already  clear,  it  should  ])e  filtered  before  boil- 
ing. In  aseptic  surgery  sterilized  water  is  indispensable  for  many 
purposes,  such  as  to  wash  the  hands,  to  cleanse  the  field  of  operation, 
to  irrigate  the  wound,  to  wash  sponges,  to  cover  instruments  in  the 
tray,  and,  when  indicated,  to  wash  out  the  peritoneal  cavity.  Ten 
gallons  should  be  sterilized  for  an  abdominal  section.  Hospitals 
usually  are  provided  witli  receptacles  for  sterilized  water.  At  the 
patient's  house  water  may  be  sterilized  and  kept  until  the  time  of  the 
operation  in  two  large  wash-boilers,  preferably  new,  in  which  it  has 
been  boiled.  It  should  be  kept  half  hot  and  half  cold,  so  that  by 
mixing,  the  right  temperature  may  be  secured. 

Sterilization  of  Towels. — Towels  should  be  of  good  quality  and  free 
from  lint ;  the  so-called  glass-towels  used  for  drying  glassware  are 
best.  They  should  be  laundered  in  the  ordinary  way,  then  boiled  in  a 
1  per  cent,  solution  of  sodium  carbonate,  ironed,  done  up  in  sterilized 
linen,  and  packed  in  a  clean  tight  box.  Twenty  towels  are  required 
for  an  ordinary  abdominal  section.  Just  before  operation  they  should 
be  re-sterilized  by  steam. 

The  Sterilization  of  Sea-sponges  by  the  usual  processes  of  washing 
and  soaking  in  antiseptic  drugs  is  tedious,  difficult,  and  not  always 
adequate.  The  uncertain  results  of  these  methods  have  led  most 
surgeons  to  abandon  sea-sponges,  and  to  substitute  for  them  the 
readily  sterilized  gauze. 

The  Sterilization  of  G-auze  Sponges  is  by  boiling  or  by  steam,  after 
the  directions  given  above  for  the  sterilization  of  towels.  They  should 
be  made  of  four  thicknesses  of  sterile  gauze,  and  should  be  six  inches 
wide  by  eighteen  to  twenty  inches  long.  Smaller  sponges  may  be 
overlooked  in  the  abdominal  cavity  and  lost,  or,  at  the  end  of  a  long 
operation  in  v.hich  many  sponges  have  been  used,  they  may  be  diffi- 
cult to  find.  The  frayed  edges  of  the  gauze  should  be  turned  in  and 
stitched ;  otherwise  loose  threads  may  stick  to  the  wound  or  be  left  in 
the  cavity  and  become  irritating  foreign  bodies.  See  precaution  rela- 
tive to  sponges  in  Chapter  VI. 

Sterilization  of  Silkworm  Gut  and  Drecsings. — Silkworm  gut  and 
gauze  dressings  may  be  sterilized  l)y  steam,  or  by  boiling,  or  by  both. 

Sterilization  of  Catgut. — Frequently  catgut  is  sterilized  by  boiling 
in  alcohol  and  then  soaking  in  antiseptic  solutions.  Not  only  are  the 
results  of  this  method  unsatisfactory,  but  numerous  distressing  injuries 
have  occurred  to  those  using  it  from  accidental  explosion  or  burning 
of  the  alcohol.  Iodized  catgut  and  catgut  sterilized  by  the  dry  heat 
process  of  Boeckmann  will  resist  absorption  only  a  few  days.  Catgut 
sterilized  by  the  chromic  acid  process  will  resist  absorption,  according 
to  circumstances,  from  ten  to  forty  days. 


44  GENERAL  PRINCIPLES. 

lodization  by  Claudius'  Solution. — For  general  use  in  abdominal  sur- 
gery iodized  catgut  should  have  the  preference  over  all  others.  The 
gut,  being  loosely  wound  on  glass  reels,  is  easily  prepared  by  soaking 
in  Claudius'  solution  of  iodine  for  eight  days,  at  the  end  of  which 
period  the  solution  is  poured  off  and  the  gut  left  in  the  same  jar, 
which  should  be  sealed.     The  solution  is  composed  of: 

Iodine  crystals,  1  part. 

Potassium  iodide,  1  part. 

Alcohol,  95  per  cent.,  50  parts. 

Water,  50  parts. 

The  Dry  Heat  Process. — The  individual  strands,  cut  in  lengths  of 
two  or  three  feet,  are  coiled,  and  each  is  double  wrapped  in  paraffin 
paper  and  placed  in  a  small  envelope  and  carefully  sealed.  The 
envelopes  then  are  placed  in  a  wire  basket.  This  is  exposed  to  dry 
heat,  284°  F.,  for  a  period  of  three  hours  on  each  of  three  successive 
days.  It  is  necessary  that  the  temperature  on  the  first  day  be  raised 
gradually  to  the  required  degree ;  this  is  because  the  gut  is  rendered 
brittle  by  a  rapid  increase  of  temperature  before  the  moisture  has  been 
dried  out  and  replaced  by  the  absorption  of  paraffin  from  the  paper. 
Let  the  temperature  be  raised  to  212°  F.  at  the  end  of  the  first  hour, 
and  maintained  at  this  point  for  one  hour  continuously ;  then  raise  it 
gradually  so  that  at  the  end  of  the  third  hour  it  will  be  284°  F.  The 
temperature  must  now  be  held  between  284°  and  300°  F,  for  three 
hours.  In  repeating  the  process  on  the  second  and  third  days  the 
temperature  may  be  raised  rapidly  to  the  required  degree. 

Ihe  Chromic  Acid  Process. — Catgut  may  be  chromicized,  as 
follows : 

1 .  Soak  the  raw  catgut,  sizes  0,  1 ,  2,  and  3,  in  Squibb's  ether  for 
fourteen  days,  changing  the  ether  twice. 

2.  Wind  on  glass  tubes. 

3.  Soak  in  an  aqueous  solution  of  chromic  acid  (1  :  3000)  for  fifteen 
to  eighteen  hours.  Catgut  soaked  for  eighteen  hours  will  resist  absorp- 
tion much  longer  than  that  soaked  for  fifteen  hours. 

4.  Boil  in  Merck's  saturated  solution  of  ammonium  sulphate  for 
twenty  minutes. 

5.  Remove  from  the  ammonium  sulphate  solution  and  rinse  for 
fifteen  minutes  in  cold  sterile  water. 

(j.  Preserve  in  air-tight  jars  containing  an  alcoholic  solution  of  mer- 
curic chloride,  1  :  2000. 

Aseptic  and  Antiseptic  Dressings,  such  as  gauze  and  absorbent 
cotton,  are  now  articles  of  commerce.  If  obtained  from  the  best 
sources,  they  may  be  reliable.  Absolutely  safe  antiseptic  and  aseptic 
gauze  may  be  prepared  readily  by  the  surgeon  or  nurse.  Many  kinds 
of  antiseptic  gauze  are  used ;  two  varieties,  however,  the  sublimated 
and  the  borated,  fulfil  all  indications.  Aseptic  gauze  is  also  neces- 
sary. Sublimated  gauze  is  useful  for  external  dressings  ;  it  is  contra- 
indicated  in  the  dressing  of  exposed  surfaces,  because  dangerous,  even 
fatal,  poisoning  has  resulted  from  absorption  of  the  bichloride  of 
mercury.  It  should  never  be  put  into  the  abdominal  cavity.  Borated 
and  aseptic  gauze  may  be  used  witli  safety  on  exposed  surfaces  or  even 
in  the  peritoneum. 


SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE.  45 

To  Prepare  Sublimated  G-auze,  boil  plain  commercial  gauze  ten  min- 
utes in  a  2  per  cent,  solution  of  sodium  carbonate,  wash  thoroughly 
with  clean  water,  boil  for  thirty  minutes  in  a  1  :  10,000  aqueous  solu- 
tion of  bichloride  of  mercury  containing  5  per  cent,  of  glycerin,  let  it 
stand  in  the  solution  for  twelve  hours  and  then  drv. 

To  Prepare  Berated  Gauze,  boil  plain  commercial  gauze  ten  minutes 
in  a  2  per  cent,  solution  of  sodium  carbonate,  wash  with  clean  water, 
boil  for  thirty  minutes  in  a  saturated  aqueous  solution  of  boric  acid, 
and  dry. 

To  Prepare  Aseptic  Gauze,  boil  plain  commercial  gauze  thirty  min- 
utes in  a  2  per  cent,  solution  of  sodium  carbonate  and  wash  with 
sterilized  water.  Plain  aseptic  gauze  is  adequate  for  all  surgical  pur- 
poses.    For  several  years  I  have  used  it  to  the  exclusion  of  all  others. 

Sterile  gloves  should  be  worn  in  handling  instruments  and  dressings 
which  are  to  be  used  in  an  operation. 

General  Precautions. — All  varieties  of  gauze  and  all  forms  of 
dressings  should  be  sterilized  by  steam  just  before  thev  are  used.  See 
description  for  dressing  abdominal  wounds  in  Chapter  VI.  The 
operating-room  should  be  clean,  well  ventilated,  well  heated,  well 
lighted,  free  from  carpets,  stuffed  furniture,  infectious  drains,  and 
every  other  object  liable  to  be  a  medium  of  infection.  Door-knobs 
and  other  parts  of  the  room,  if  liable  to  be  in  contact  with  the  hand 
of  the  o])erator  or  his  assistants,  should  be  covered  with  aseptic  gauze. 

3.  Preparation  of  the  Patient. — The  antiseptic  preparation  of 
the  patient  has  a  twofold  purpose  :  First,  to  remove,  destroy,  and 
limit  the  power  of  pathogenic  bacteria ;  this  requires  the  local  appli- 
cation of  antiseptic  measures  to  the  abdomen,  external  genitals,  and 
vagina.  Second,  to  enable  the  patient  to  resist  any  bacteria  that  may 
remain  or  develop.  This  may  require  both  regulative  and  medicinal 
treatment.  A  searching  general  examination  from  the  standpoint  of 
internal  medicine  should  be  made  in  every  case.  This  examination 
may  show  phthisis  or  diabetes,  or  some  other  contraindication  or  condi- 
tion which  would  make  the  operation  extra-perilous.  Then  the  pre- 
paratory treatment  should  be  directed  to  that  condition.  To  be  fore- 
warned is  to  be  forearmed. 

When  the  operation  is  not  one  of  emergency  the  preparation  may 
well  include  several  days  of  observation  and  treatment.  In  this  way 
often  the  patient's  peculiarities  may  be  measured,  and  her  power  to 
resist  infection  may  be  increased.  The  abdominal  and  thoracic  organs 
should  be  examined,  especially  the  lungs,  heart,  and  kidneys.  A  quan- 
titative examination  of  urine  may  show  a  deficiency,  for  example,  of 
urea ;  then  a  few  days  of  judicious  diet  and  diuretics  may  turn  the 
result  of  an  operation  in  the  patient's  favor.  The  daily  general  bath, 
with  friction,  besides  being  an  antiseptic  measure,  increases  the  action 
of  the  skin  and  relieves  the  kidneys. 

The  Drinking  of  Water  in  large  quantities  during  the  week  before 
a  capital  operation  is  most  advantageous  and  when  practicable  never 
to  be  neglected.     Three  or  four  pints  a  day  should  be  taken. 

The  Bowels. — Bowel  distention  impedes  the  operator  and  lengthens 
the  operation.     It  is  a  dangerous  complication  both  during  and  after 


46  GENERAL  PRINCIPLES. 

the  operation,  and  is  the  cause  of  a  great  deal  of  mortality.  So  far 
as  practicable,  then,  let  the  bowels  be  emptied  of  gases  and  solids  and 
of  %vhatever  may  ferment  and  form  gas.  Experiment  has  shown  that 
the  countless  myriads  of  bacteria  habitually  present  in  the  intestine 
may  be  reduced  by  catharsis  and  intestinal  antiseptics  to  a  relatively 
insignificant  number ;  hence  the  following  measures  are  suggested  to 
render  the  bowels,  as  nearly  as  possible,  aseptic : 

1 .  For  several  days  before  the  operation  exclude  all  food  that  is 
apt  to  ferment. 

2.  On  the  third  night  before  the  operation  give  five  grains  of  blue 
mass.  If  the  bowels  do  not  act  freely  the  next  morning,  give  an 
ounce  of  castor  oil.  On  the  day  before  the  operation  give  a  Seidlitz 
powder  or  some  other  active  saline  purge.  Two  compound  cathartic 
pills  may  be  substituted  for  the  blue  mass.  Repeat  the  cathartics  if 
necessary.  A  large  dose — Jounces — of  castor  oil  one  or  two  days 
before  the  operation  is  most  satisfactory  and  may  take  the  place  of  all 
other  cathartics. 

3.  Give  repeated  high  copious  enemas  during  the  tAvo  days  before 
the  ojieration.  The  enemas  may  be  of  soapsuds,  each  pint  con- 
taining, thoroughly  mixed,  a  drachm  of  turpentine.  Persevere  in 
this  until  no  considerable  amount  of  gas  remains.  If  the  turpentine 
and  soapsuds  enema  does  not  suffice,  try  a  mixture  containing  two 
ounces  each  of  glycerin,  Epsom  salt,  and  water.  Use  a  flexible  rectal 
tube  with  firm  walls,  three  feet  long,  and  give  the  enema  as  high  as 
possible: 

Cleansing  the  Field  of  Operation. — Every  abdominal  section  may 
require,  for  drainage  or  for  other  reasons,  that  an  opening  be  made 
from  the  peritoneal  cavity  into  the  vagina ;  hence  the  necessity  of 
cleansing  not  only  the  abdominal  wall,  but  also  the  vaginal  surfaces 
and  external  genitals. 

Cleansing  the  Abdomen  to  Prevent  Stitch-hole  Abscesses. 
— Twenty-four  hours,  or,  if  possible,  forty-eight  hours  before  operation 
the  entire  abdominal,  pudic,  and  perineal  areas  are  shaved  carefully, 
including  not  only  the  coarse  hair,  but,  so  far  as  possible,  the  white 
downy  hairs,  especially  those  about  the  navel.  A  poultice  of  liquid 
antiseptic  soap,  already  described,  is  then  placed  over  the  abdomen, 
including  the  epigastrium,  and  allowed  to  remain  one  and  one-half 
hours  ;  upon  the  removal  of  this  poultice  the  remaining  soap  is  washed 
off  first  with  sterile  water,  and  then  with  commercial  ether.  The  abdo- 
men then  is  covered  with  thick  layers  of  gauze  wet  with  an  aqueous  mer- 
curic bichloride  solution,  1  :  3000,  the  Avhole  being  covered  with  oiled 
muslin  or  gutta  percha  and  an  abdominal  binder.  This  dressing  is 
rewet  every  four  hours  and  retained  until  three  hours  before  the  ope- 
ration, when  fresh  sterile  gauze  wet  with  a  1  :  2000  alcoholic  mercuric 
bichloride  solution  is  sul)stituted  and  retained  until  the  patient  is 
under  anaesthesia.  The  last  dressing  then  is  removed  and  over  the 
abdomen  liquid  antiseptic  soap  containing  ether  is  poured.  The  um- 
bilicus is  filled  completely  with  soap.  As  little  water  as  possible  is 
used,  and  the  soap  is  worked  up  into  a  layer  of  paste,  a  towel 
being  used  for  the  purpose  instead  of  a  brush.     The  entire  abdo- 


SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE.  47 

men,  epigastrium,  and  hips  are  scrubbed  until  a  delicate  erythema  is 
produced.  The  umbilicus  is  cleansed  carefully  and  the  soap  washed 
off  thoroughly  with  sterile  water.  The  abdomen  then  is  dried  with  a 
sterile  towel,  and  over  the  whole  area  sublimated  alcohol,  1  :  2000,  is 
poured.  The  umbilicus  is  filled  with  sublimated  alcohol,  to  be  mopped 
out  with  gauze  just  before  the  initial  incision  is  made.  The  reason 
for  working  the  soap  into  a  paste  with  as  little  sterile  water  as  possi- 
ble is  because  the  excess  of  alkali  saponifies  the  fat  of  the  skin  and 
probably  destroys  the  capsules — i.  e.,  outer  coverings — of  the  micro- 
organisms. 

The  rationale  of  preparing  a  large  area  when  only  a  small  portion 
of  the  abdomen  is  to  be  incised  is  that  in  some  cases  the  incision  may 
have  to  be  extended  greatly  so  that  skin  surfaces  which  one  has  no 
]irevious  idea  of  handling  may  come  in  contact  with  the  hands  or 
gloves.  A  process  so  extensive  and  detailed  as  this  may  seem  unnecessary, 
but  there  is  proof  that  it  almost  entirely  prevents  wound-infection  and 
stitch-hole  abscesses. 

Cleansing  the  External  Pudenda  and  Vagina, — The 
mons  veneris  and  vulva  having  been  shaved,  three  vaginal  douches 
are  to  be  given  on  each  of  the  three  consecutive  days  before  the  opera- 
tion. Each  douche  should  consist  of,  first,  strong  soapsuds  made  of 
green  soap;  second,  sterilized  water;  third,  solution  of  bichloride  of 
mercury,  1  :  3000. 

Just  before  beginning  an  operation,  when  the  patient  is  under  the 
anesthetic,  the  external  genitals  and  surrounding  parts  should  be 
scrubbed  thoroughly  with  a  large  sterile  towel,  and  the  vagina  should 
be  scrubbed  and  swabbed  out  with  a  wad  of  gauze  in  the  grasp  of  a 
long  haemostatic  forceps.  Sterilized  green  soap  or  the  liquid  antiseptic 
soap  already  described  should  be  used.  All  soap  should  now  be 
washed  away  by  a  stream  of  sterilized  water  poured  from  a  pitcher, 
and  the  parts  further  sterilized  by  filling  the  vagina  with  a  1  :  3000 
70  per  cent,  alcoholic  solution  of  Jjichloride  of  mercury.  Finally  the 
vagina  should  be  packed  with  a  continuous  strip  of  gauze  saturated 
with  the  same  solution  ;  this  packing  should  remain  in  the  vagina 
during  the  operation  unless  it  becomes  necessary  to  open  from  the  peri- 
toneum into  the  vagina,  in  which  case  the  gauze  should  be  removed  ; 
it  insures  asepsis  of  the  vagina  and  is  a  precaution  of  the  utmost 
moment,  in  view  of  the  possibility  of  opening  from  the  pelvic  cavity 
into  the  vagina. 

Curettage. — It  is  wise,  especially  in  a  case  of  infectious  endo- 
metritis, to  curette  and  disinfect  the  endometrium  before  jiroeeeding 
to  open  into  the  pelvic  cavity.  This  precaution  may  prevent  post- 
operative infection  in  the  pelvic  cavity  by  extension  from  the 
uterus. 

In  the  giving  of  the  douche  the  familiar  Kelly  pad  will  be  found 
more  useful  and  more  practical  than  the  bed-pan.  The  objections 
to  this  pad  are,  first,  that  it  is  not  always  obtainable ;  second,  it  is 
difficult  to  keep  clean,  and  is  therefore,  for  surgical  purposes,  apt  to 
be  septic. 

The  writer   uses   a   practical  substitute    for   the    Kelly  pad  that 


48 


GENERAL  PRINCIPLES. 


obviates  both  objections.  It  is  simply  a  piece  of  sheet  rubber,  three 
feet  wide  and  four  and  one-half  feet  long.  The  rubber  sheet  at  its 
upper  end  and  sides  is  folded  over  rolls  of  toweling  or  muslin,  so  that, 
as  in  Kelly's  pad,  the  water  will  be  directed  into  the  bucket  below. 
See  Figure  9.  Rubber  sheeting  is  available  everywhere,  is  cleaned 
easily,  and  is  so  inexpensive  that  it  may  be  renewed  frequently.  Sheet- 
ing which  has  the  rubber  finish  on  both  sides  is  preferable.  The  ordi- 
nary oil-cloth  used  to  cover  a  kitchen  table  is  serviceable,  and  may  be 
obtained  in  almost  every  house. 

Figure  9. 


Practical  substitute  for  the  Kelly  pad. 


Protection  for  the  Feet  and  Legs. — When  the  patient  is  placed  on  the 
table  before  the  anaesthesia  begins,  it  is  well  to  cover  her  feet  and  legs 
with  long  sterilized  flannel  stockings. 


Preparations  of  an  Aseptic  Vaginal  Operation, 

The  surgery  of  the  vaginal  portion  of  the  pelvic  floor  is  classified 
usually  under  the  head  of  minor  operations.  This  designation,  since 
it  implies  that  the  operations  are  trivial  and  safe  even  without  full 
precautions,  is  misleading  and  dangerous.  High  vaginal  amputation 
of  the  cervix   uteri  and  the  removal  of  an  intra-uterine  tumor  by 


SEPTIC  INFECTION  AND  ASEPTIC  TECHNIQUE.  49 

iiiorcellement,  for  example,  are  clearly  major  operations.  Curettement, 
perineorrhaphy,  trachelorrhaphy,  dilatation  of  the  cervix,  closure  of 
vaginal  fistulas,  though  relatively  safe,  are  in  an  absolute  sense  dan- 
gerous. Failure  to  observe  aseptic  technique  in  vaginal  operations, 
although  less  frequently  fatal,  is  yet  full  of  danger.  The  possibility 
of  a  fatal  pneumonia,  nephritis,  phlebitis,  or  lymphangitis  as  the  direct 
result  of  an  unclean  ''  minor "  vaginal  operation  is  not  sufficiently 
appreciated.  The  same  cleansing  process  as  set  forth  above  for  abdom- 
inal section  is  imperative. 

The  Asepsis  of  Minor  Manipulations  and  Examinations. 

Since  the  unclean  uterine  probe  repeatedly  has  caused  fatal  metro- 
peritonitis, and  since  "  death  has  been  carried  to  many  a  woman  under 
the  finger-nails,"  it  follows  that  the  same  principles  which  apply  to 
surgical  work  also  hold  good  in  the  ordinary  routine  examinations  and 
local  treatment  of  the  pelvic  organs. 

Asepsis  of  the  Patient. — Sterilization  of  the  endometrium,  vagina, 
and  vulva  preparatory  to  ordinary  office  manipulation  is  impractica- 
ble, not  to  say  impossible.  Reasonable  safety  is  secured,  however,  by 
the  hot  vaginal  douche  which  the  patient  usually  takes  before  apply- 
ing for  treatment.  As  a  supplement  to  this  it  is  best  to  wipe  out  the 
vagina  with  dry  absorbent  cotton  on  long  lock  forceps,  and  then  with 
absorbent  cotton  saturated  with  a  5  per  cent,  solution  of  carbolic  acid 
in  glycerin,  or  with  a  1  :  2000  aqueous  solution  of  bichloride  of 
mercury.  Disinfection  of  the  vagina  or  vulva  in  this  way  is  especially 
essential  if  the  uterine  cavity  is  to  be  instrumentally  or  digitally 
explored  or  treated.  By  this  means  the  endometrium  is  protected 
against  the  entrance  of  septic  matter,  which  otherwise  may  easily  be 
carried  in  from  the  vulva  or  vagina  on  the  instrument — a  very  com- 
mon mode  of  infection. 

Asepsis  of  the  Hands  ;  Rubber  Gloves. — The  cleaning  and  dis- 
infection of  the  hands  and  nails  before  and  after  the  most  ordinary 
digital  examination  are  imperative,  not  only  to  guard  against  the  car- 
rying of  infection  from  patient  to  patient,  but  to  prevent  self-inocula- 
tion with  specific  or  non-specific  virus  through  some  abrasion  upon  the 
hand.  The  nails  should  be  trimmed  short ;  what  has  been  said  about 
rubber  gloves  in  surgery  is  equally  applicable  here  in  the  interest  of 
the  patient  and  more  applicable  in  the  interest  of  the  examiner.  By  the 
use  of  gloves  for  examination  many  a  physician  would  be  saved  from 
the  calamity  of  specific  and  other  infections. 

Asepsis  of  the  Instruments. — The  former  practice  of  simply 
washing  instruments  in  soap  and  water  after  each  treatment  is  unsafe. 
Ordinary  washing  does  not  remove  micro-organisms.  Surgical  clean- 
liness may  be  secured  by  washing  the  instruments  in  hot  water  and 
green  soap  and  boiling  them  for  five  minutes  in  a  3  per  cent,  solu- 
tion of  sodium  carbonate.  It  is  convenient  for  this  purpose  to  have 
always  during  the  office-hour  a  deep  tray  of  the  solution  constantly 
boiling  over  the  flame  of  a  spirit-lamp  or  a  gas-burner,  or  more  con- 
venient to  have  several  set  of  instruments,  which  may  be  used  one 
4 


50  GENERAL  PRINCIPLES. 

after  the  other,  and  then  all  disinfected  together  at  the  end  of  the 
office-hour. 

The  Lubricant  of  Vaseline  or  Oil,  usually  kept  near  the  exami- 
nation-table, is  unnecessary  for  lubricating  purposes  when  the  natural 
secretions  are  profuse  and  themselves  serve  that  purpose.  Some  arti- 
ficial lubricant  is  always  useful,  however,  to  protect  the  operator's 
fingers  against  infection ;  but  the  lubricant  is  often  a  source  of  sepsis 
in  itself,  or  it  may  easily  become  so  by  contact  with  the  unclean  finger 
or  instrument.  Gronorrhoeal  and  other  infection  frequently  is  carried 
from  patient  to  patient  n  this  way.  Neither  fingers  nor  instruments, 
thei'efore,  should  come  in  contact  with  the  lubricant  unless  they  are 
free  from  vaginal  and  other  secretions — unless  absolutely  clean.  The 
lubricant  should  be  aseptic  and  non-irritating.  Olive  oil  and  vase- 
line are  often  septic  and  difficult  to  wash  oflP.  Soap  is  apt  to  irritate 
the  sensitive  vulva.  For  several  years  the  author  has  used  glycerin. 
It  is  a  most  excellent  lubricant  and  deodorant.  Even  after  digital 
examination  of  extremely  fetid  uterovaginal  cancer,  the  foul  nauseat- 
ing order,  usually  so  lasting,  may  be  washed  off  the  examiner's  hand 
by  placing  it  under  a  stream  of  running  water,  if  before  the  examina- 
tion the  hand  was  lubricated  freely  with  glycerin.  For  this  purpose 
a  superior  quality  of  glycerin  is  required.  Tn  cancer  and  other  septic 
cases  gloves  should  be  worn. 

Glycerin  Emollient. — The  adaptability  of  glycerin  for  this  purpose 
has  led  to  the  preparation  of  a  glycerin  ointment.  It  is  put  up  in  soft 
metallic  collapsible  tubes,  such  as  are  used  for  vaseline  and  paints. 
The  ointment  is  forced  out  of  the  tube  by  compressing  the  bottom 
between  the  thumb  and  finger  and  folding  the  flattened  end  as  the  tube 
is  emptied.  The  use  of  the  tube  obviates  the  risk  of  contaminating 
the  lubricant  by  the  soiled  fingers.  The  preparation  is  a  sterilized 
combination  of  the  following  ingredients  :  oil  of  gaultheria,  2  gm.;  boric 
acid,  23  gm.;  corn-starch,  88  gm.;  pure  glycerin,  885  gm.;  tragacanth, 
17  gm.  The  formula  is  the  outcome  of  numerous  experiments  by 
Parke,  Davis  &  Company,  who,  upon  the  author's  suggestion,  have 
perfected  the  preparation.  It  is  furnished  by  them  under  the  name 
"  Glycerin  Emollient." 

A  Word  of  Caution. — Many  a  distressing  pelvic  infection  owes  its 
origin  to  meddlesome  office  gynecology.  Instrumental  invasion  of  the 
endometrium  and  other  manipulations  which  require  much  force  are 
procedures  which,  under  any  conditions,  may  be  far  from  trifling.  The 
physician's  office  does  not  furnish  for  them  a  uniformly  safe  environ- 
ment. They  require  and  should  have  the  safeguards  of  the  home  or 
the  hospital. 


CHAPTER  III. 

DIAGNOSIS. 

The  subject  of  diagnosis  is  divided  into  two  parts  :  first,  the  clinical 
history  ;  second,  the  physical  examination. 

THE  CLINICAL  HISTORY. 

Before  asking  questions  or  recording  any  of  the  history  it  is  well 
to  let  the  patient  make  her  own  statement  without  suggestion  ;  this 
will  relieve  her  of  nervousness  and  compose  her  mind  for  the  syste- 
matic questioning. 

Histories  usually  are  kept  in  blank  case-books  printed  and  bound 
for  the  purpose.  A  very  practical  way  is  to  keep  them  in  individual 
envelopes,  made  of  strong  manila  paper,  each  history  in  an  envelope 
by  itself,  with  the  name,  residence,  and  date  of  the  first  visit  written 
across  the  end.  The  histories  are  kept  in  alphabetically  arranged 
pigeon-holes,  where  they  may  be  found  readily.  The  great  advantage 
of  this  plan  is  that  the  histories  may  be  written  away  from  the  office 
on  scraps  of  paper,  and  do  not  have  to  be  copied,  but  may  be  filed 
away  together  with  any  subsequent  correspondence,  prescriptions,  or 
additional  notes. 

Form  for  Record  of  Cases. — The  skeleton  form  given  on  the  fol- 
lowing pages  is  suggested  for  the  convenient  and  systematic  record  of 
cases.  The  printed  blank  is  subject  to  such  erasures  and  additions  as 
the  individual  case  may  require.  In  using  such  a  blank  one  must 
keep  in  mind  the  fact  that  no  stereotyped  form  can  include  sugges- 
tions for  all  the  points  that  are  liable  to  come  up  in  connection  with  a 
case.  Unless,  therefore,  one  supplements  the  inquiry  by  such  ques- 
tions as  each  special  case  may  call  for,  he  will  fall  into  a  dangerous 
routine. 

The  record  form  which  follows  will  help  the  student  and  young 
practitioner  to  form  the  habit  of  accurate  and  systematic  diagnosis. 
As  one  gains  experience  and  automatic  grasp,  and  judges  less  from 
multiform  details  and  more  from  principles,  he  will  eliminate  grad- 
ually from  his  histories  and  records  all  that  is  not  essential  to  the 
efficient  analysis  of  his  cases.  A  few  general  statements  then  may 
serve  the  ])urpose  of  a  practical  memorandum. 

In  recording  a  case  one  may  use  conveniently  al)breviations  and 
signs,  for  example,  the  plus  sign  (+),  the  minus  sign  ( — ),  the  plus  or 
minus  sign  (±),  the  zero  sign  (0),  the  sign  of  equality  (=);  and  the 
letter  n  may  signify  (+)  excessive,  ( — )  less  than  normal,  (±)  variable, 
(0)  no,  none,  or  negative  results,  {=)  equals  or  amounts  to,  (n)  nor- 
mal ;  V.  s.  =  0  would  be,  for  example  a  short  expression  to  indicate 
the  absence  of  vesical  symptoms. 

51 


52  GENERAL  PRINCIPLES. 


RECORD  OF  A  CASE; 

ABBREVIATIONS:    The  sign  +  signifies  excessive;  — ,  less  than  normal;  v,  variable;  0,  no,  none  or  negative  results; 
^  y?       "■  signifies  normal. 

M/lA...U:imi....../^^  AMresjA.P....../3^.a^....S^^ 

AgeHD..Dale  of  first  c<)nsuUation.(u^i*.^,^^<^f'^ra^..J...t....  

Recommended  by  .2>.rd^hi£J!AJ:XL'^^....l^^ 

I.  l^3&OD3iiiy{4A4'^-^'^^^<^^<^--0ccupaiw^  Dates  illness Jrom 

2.^mgle,  Married,  WHxrn J  J^years.    3.   Well,rH developed.    A'Ktiijmi* gi)i>d anemic.pielkerk. 
4.  Family  History  t>»< 


5.  Mensed;  First  menses  at  age  /-^-.  AJaays,  usually  regular,  irivgie/ai;  every. :^rTTrrrrM'^a^ days , ■ 
■continuesP.--f-Jo.-/..J.  .(fays^  Amount,  iwi-mal,,  imall,  large,  tli>Sk"di  ..  /\\.....  Color.  Last 
««.«./{(r:Ji.^M»*^-;y^  ended  ../JU.-^  . /^Y./^/Z?..... 

&  Dvsmenofrhoea ;  ■     /   ■ pain  inguinal,  right  and  left,  shooting  down  ihighs,  hypogastric, 

lumbar,  bearing  down,    constant,    f<>mU^^3nt^  in(\;rmHiL'n(.     v.i^4fiX~*Pi. tfr>>rC dayt^~ 

before, -i^i^^^^ -during,  —   ■■  nifk-r flow.     In  bed >7^ days. 

7.  InUrmenstrual  Pain:...^.....^^^:tJ^:10rV 

Jttv^Mofit,  i>isi(*(iMiii  ifiti.t'miiicnS)i  iu>iii'lint    ^ Walkmg  and  especially  standing 

cause  bearing  down,  sensation  and  exhaustion -..X't^^^yC^L^-^-.^^^rr:^-'^:-^^ 

8.  Children:  Number-^. ;  oldest -^- ^ youngest— .ii>..^    Labors  uairmal,  rapid,  tcdicius^  iiistrufHun/aJ. 

^^l^^^c^r^^^^X.d:jC/3^^  ,•„  l,ed...^...weeks.     Getting  up  ««AV  ill:rp..ir>^'hh^ 

9.  Abortions:  Number..%m...;  first  at  .^-niontlU ;  last  at  ■■^■—months.    In  bed-^----weeks.g,6,-'V^iiCL*--.^ 


JO.  Leucorrhoea:   First  appearance— ^■JlO'^*'*^'*^- ago.    Bleedy,  pusruUfit\  iiiuco-purulent,  miix.\)ivs, 
<h-''-\  "'v.  r -frin  1  ii^ii  ifi  glairy,  offensive.      Constant  worse  before,  ^ttttng,  after  menstruation. 

tJ.  Bladder  Symptoms:    Jfcfyuriai  infotitifiuife  reimatievif  dystirim.     Urinates-^^^times  during  night, 
'zi^ -times  during  day.    Frequency  feit  increased  by  standing  or  walking 

J2.  Dit^estion:     Teeth aT-.v* ,-  appetite --^ss-:  eating  causes      ~  t"^ distress,  distention, 

nausea,   vamiiitig,   eructation,  flatulence,^cidity,   iKunvedia/Wy,  an  hour  or  two  after  eating. 
Regular  habits  of  eating.      Kinds  of  food CC-'*-<C ,  tea,  coffee,  <ili.\}h\}i. 


13.    Bowels:    R^g  m^".  constipation  and  diarrhaa,  alternating.    Action  fttU,  scanty,  Ji^tiid,  offensive, 
bloody,  rluicoHS,  pii'nlei\/i    Painful  at  times  in  pelvis,  at  anus.       Culuf- 


i7  Oyu^t^im^^y.c<.  >**-'e^    A-'vTa /yC 


DIAGNOSIS.  53 


J4.    Nervous  System  t    Sleeps  fiZ'^^^'^^^'f- Hyatiria,  /mm  lyfis,  nervousness,  neurasthenia. 


15.    Extra  Pelvic  Organs:   ^  ^^^nAdj:Pt:ri'l.jl.M^ 

\£.  T5 • Tit .       /i/7  Ar~^(/  y       /""  ^  ^  ^  j^>^^  ^'       '^i^^ 


J6.  Previous  Illnesses : 


17.  Seeks  Relief  l^t  AZ^Ua^p^X^/lie'^i^^ 

J9.  Urinalysis:   Amount  in  2^  hours   ■■7.0....^rX _.    Sp. gr...l.0O  S .,    Reaction f^  ' --. 

CoIor^yiy^f^VwtAlbumen-y.O.y...  'iugar-.O.y....  Urca/'/.Y'U    Total  Solids.  ^Z.^-: 
SedimenVby  ZenterfugAid^^a^iA    Microscopical  Examination -/<?'Z-^^^<:^?r::^?*rX... 

20.  Physical  Examinatioa,  Diagnosis  aixl  Treatment  i 

f  .  lCti}uAxJL  a/jA^X^j^  ^'yl^  i^a^]  $^^^/litw^.  cu^ 


54  GENERAL  PRINCIPLES. 

The  hypothetical  case  outlined  in  the  history  blank  is  not  out  of 
the  comraon.  The  patient  had  been  a  well-developed  Moraan,  of  good 
family  history.  The  menstrual  and  other  functions  had  been  perfectly 
normal  until  after  the  hrst  child  was  born.  Then  came  the  abnormal 
developments  recorded  in  sections  6  to  19.  Neglected  lacerations  of 
tiie  cervix  and  perineum  opened  the  door  for  the  entrance  of  infec- 
tion ;  hence  infection  spread  through  the  endometrium  and  possibly 
also  through  the  parametric  lymphatics  and  veins  to  the  tubes, 
ovaries,  and  adjacent  peritoneum.  Adhesions  formed,  binding  the 
uterus  with  its  appendages  together  in  posterior  displacement ;  this 
displacement  was  increased  and  perpetuated  by  the  excessive  weight 
of  the  uterus,  by  impairment  of  support  from  the  lacerated  perineum  ; 
that  is,  from  injury  to  the  pelvic  floor  and  from  the  uow  relaxed,  sub- 
involuted  state  of  all  the  pelvic  organs  and  their  supports. 

Endometritis  and  metritis  give  rise  to  menorrhagia  and  leucorrhoea, 
which  explains,  partly  at  least,  the  anaemia,  neurasthenia,  nervous  irri- 
tation, and  impaired  general  nutrition.  Difficulty  of  Malking  and 
standing,  both  from  general  weakness  and  from  displacement  of  the 
pelvic  organs,  interferes  with  necessary  exercise,  and  still  further  adds 
to  the  causes  of  malnutrition.  The  increased  frequency  of  urination 
when  the  patient  is  on  her  feet  may  be  explained  by  the  fact  that  the 
organs  at  that  time  descend  to  a  lower  level  and  drag  on  the  bladder. 
Intestinal  indigestion,  sluggish  liver,  faulty  metabolism,  constipation, 
deficiency  of  urea  and  of  other  urinary  solids,  excess  of  uric  acid,  and 
finally  chronic  interstitial  nephritis,  are  associated  not  uncommonly 
with  pelvic  traumatism  and  infection. 

The  difficulties  of  gynecological  diagnosis  often  are  increased  by  the 
fact  that  pelvic  lesions  may  exist  and  cause  no  definite  local  symptoms. 
Even  greater  confusion  may  arise  from  the  presence  of  pelvic  symp- 
toms which  are  caused  not  by  pelvic,  but  by  extrapelvic,  disorders. 

The  nerve  counterfeits  of  pelvic  disease  are  most  realistic  and 
bewildering,  and  have  been  expressed  well  in  the  following  paragraphs 
by  the  late  William  Goodell : 

"  Nerve-strain,  or  nerve  exhaustion,  comes  largely  from  the  frets, 
the  griefs,  the  jealousies,  the  worries,  the  bustles,  the  carks  and  cares 
of  life.  Yet,  strangely  enough,  the  most  common  symptoms  of  this 
form  of  nerve  disorder  in  women  are  the  very  ones  which  lay  tradi- 
tion and  dogmatic  empiricism  attribute  to  ailments  of  the  womb. 
They  are,  in  the  usual  order  of  their  frequency,  great  weariness  and 
more  or  less  nervousness  and  wakefulness,  inability  to  walk  any  dis- 
tance, and  a  bearing-down  feeling ;  then  headache,  napeache,  and 
backache.  Next  come  scanty,  or  painful,  or  delayed,  or  suppressed 
menstruation,  cold  feet,  and  irritable  bladder ;  general  spinal  and 
pelvic  soreness  and  pain  in  one  ovary,  usually  the  left,  or  in  both 
ovaries.  The  sense  of  exhaustion  is  a  remarkable  one  :  the  woman  is 
always  tired ;  she  spends  the  day  tired,  she  goes  to  bed  tired,  and  she 
wakes  up  tired — often,  indeed,  more  tired  than  when  she  fell  asleep. 
She  sighs  a  great  deal ;  she  has  low  spirits,  and  she  often  fancies  that 
she  will  lose  her  mind.  Her  arms  and  legs  become  numb  so  fre- 
quently that  she  fears  palsy  or  paralysis.  Nor  does  the  skin  escape 
the  general  sympathy.     It  becomes  dry,  harsh,  and  scurfy,  and  pig- 


DIAGNOSIS.  55 

mentary  deposits  appear  under  the  eyes,  around  the  nipples,  and  in 
the  chin  and  forehead.  The  symptom-group  of  nervous  exhaustion 
— anaemia,  backache,  bearing-down,  difficult  walking,  ovarian  pain, 
and  menstrual  disorders — although  often  without  the  least  gyneco- 
logical significance,  is  usually  the  signal  for  a  gynecological  diagnosis. 
Any  pelvic  organ  showing  the  slightest  irregularity  is  singled  out  as 
the  culprit  and  promptly  placed  on  trial.  Endless  injurious  local 
treatment  and  grave  surgical  operations  may  now  cause  the  woman  to 
suffer  many  things  from  many  physicians." 

As  Goodell  aptly  remarks  :  "  If  no  tangible  disorder  of  the  sexual 
organs  be  discoverable,  the  invisible  endometrium  or  ovaries  must  take 
the  blame  and  receive  the  local  treatment.  Whatever  the  inlook  or 
the  outlook,  a  local  treatment,  more  or  less  severe,  is  liable  to  be  the 
issue.  Yet  these  very  exacting  symptoms  may  be  due  wholly  to 
nerve-strain,  or,  what  is  synonymous,  to  loss  of  brain-control  over  the 
lower  nerve-centres,  and  not  to  direct  or  to  reflex  action  from  some 
supposed  uterine  disorder.  Neither,  for  that  matter,  may  they  come 
from  some  real,  tangible,  and  visible  uterine  lesion  which  positively 
exists.  Thus  it  happens  that  a  harmless  anteflexion,  a  trifling  leucor- 
rhoea,  a  slight  displacement  of  the  womb,  a  small  tear  in  the  cervix, 
an  insignificant  rent  of  the  perineum,  or,  what  is  almost  always  pres- 
ent, an  ovarian  ache,  each  plays  the  part  of  the  will-o'-the-wisp  to 
allure  the  physician  from  the  bottom  factor.  To  these  paltry  lesions 
— because  they  are  visible,  palpable,  and  ponderable,  and  because  he 
has  by  education  and  by  tradition  a  uterine  bias — he  attributes  all  his 
patient's  troubles ;  whereas  a  greater  and  subtler  force,  the  invisible, 
impalpable,  and  imponderable  nervous  system,  may  be  the  sole  delin- 
quent. The  sufferer  may  be  a  jilted  maiden,  a  bereaved  mother,  a 
grieving  widow,  or  a  neglected  wife,  and  all  her  uterine  symptoms — 
yes,  every  one  of  them — may  be  the  outcome  of  her  sorrows  and  not 
of  her  local  lesions.  She  is  suffering  from  a  sore  brain,  and  not  from 
a  sore  womb." 

We  may  admit  the  extreme  wisdom  of  Goodell's  summing  up  ;  at 
the  same  time  we  must  insist  that  an  exhaustive  analysis  of  a  patient's 
condition  often  will  lead  to  conclusions  less  imponderable  than  his  ex 
parte  statement  would  imply.  The  case  above  outlined  on  the  record 
blank  will  not  only  show  an  example  of  possible  diagnosis ;  but,  if 
analyzed,  will  show  also  that  the  cure  of  aggravated  local  lesions  may 
not  result  in  the  complete  recovery  of  the  patient ;  such  cure,  will, 
however,  be  an  important  step  in  the  right  direction.  A  common 
mistake,  when  there  are  other  more  general  and,  perhajxs,  more  serious 
anomalies,  is  to  expect  prompt  and  complete  relief  upon  the  correction 
of  local  lesions.  It  would  also  be  equally  a  mistake  to  follow  the 
possible  implication  of  Goodell,  and,  because  we  know  that  local  treat- 
ment of  palpable  local  lesions  cannot  completely  cure  the  patient,  fiiil 
to  give  that  treatment,  and  thereby  fiiil  to  cure  her  so  fiir  as  we  can. 
It  is,  moreover,  improbable  that  a  harmless  anteflexion,  a  trifling 
leucorrhoea,  a  slight  displacement  of  the  womb,  a  small  tear  of  the 
cervix,  an  insignificant  rent  of  the  perineum,  or  an  ovarian  ache  would 
often  lead  a  serious  practitioner  away  from  the  "bottom  factor"  to 
useless  or  injurious  gynecological  treatment. 


56  GENERAL   PRINCIPLES. 

Not  less  essential  than  the  gynecological  part  of  the  record  is  that 
which  belongs  to  the  general  condition  of  the  patient.  Age,  tempera- 
ment, bodily  habit,  heredity,  color,  the  heart  and  bloodvessels,  the 
digestive  tract,  the  liver,  spleen,  and,  even  more  important,  the  kid- 
neys, all  demand  close  and  careful  attention. 

THE  PHYSICAL  EXAMINATION. 

Examination  calls  into  use  the  special  senses,  supplemented  by  such 
conditions,  instruments,  and  appliances  as  will  increase  the  power  or 
widen  the  range  of  the  senses. 

The  conditions  to  be  fulfilled  for  an  adequate  examination  are  num- 
erous and  variable.  Among  them  are  :  1.  Cleanliness.  2.  A  suitable 
table.  3.  Proper  attitude  and  position  for  the  patient,  and  empty 
bladder  and  rectum. 

Cleanliness  and  Asepsis  have  been  emphasized  in  the  last  chap- 
ter ;  their  importance  cannot  be  exaggerated.  Exception  :  if  it  is 
desired  to  study  the  character  of  the  uterine,  vaginal,  or  vulvar 
secretions,  the  preliminary  douche  and  disinfection  of  the  parts  may 
be  omitted. 

The  Rectum  and  Bladder  should  be  empty  for  the  following 
reasons  :  1.  These  viscera,  when  full,  displace  the  pelvic  organs  by 
pressure.  2.  Retained  feces  and  urine  may  be  mistaken  for  solid  and 
cystic  tumors.  The  full  bladder  pushes  the  uterus  and  its  appendages 
upward  and  backward  and  greatly  increases  the  difficulty  of  conjoined 
examination.  Even  a  small  quantity  of  urine  in  the  bladder  may 
cause  the  patient  to  make  the  abdominal  muscles  so  tense  that  the 
uterus  cannot  be  felt  between  the  hand  over  the  pubes  and  the  exam- 
ining finger  in  the  vagina.  A  preliminary  cathartic  to  clear  the  bowels 
of  feces  and  gas  should  therefore  precede  the  first  examination. 

The  Examining  Table. — The  digital  examination  may  be  made 
with  the  patient  lying  on  a  sofa  or  bed  ;  but,  as  Marion  Sims  has 
taught,  "  the  one  is  too  low  and  the  other  is  too  soft  and  yielding  for 
a  speculum  examination."  Even  the  digital  touch  and  palpation  are 
much  better  made  on  a  table.  If  the  bed  is  used,  the  patient  should 
lie  across  it,  with  the  hips  well  to  the  edge,  and  not  lengthwise  of  the 
bed.  The  table  is  essential  for  a  thorough  speculum  examination. 
The  conventional  office  chair,  although  less  objectionable  than  the  sofa 
or  bed,  is,  by  comparison  with  the  table,  inferior.  An  ordinary  pine 
kitchen  table,  two  feet  wide,  four  feet  long,  and  two-and-one-half  feet 
high,  covered  with  a  blanket  and  sheet  and  supplied  with  a  pillow, 
will  answer  every  purpose  almost  as  well  as  tlie  more  elaborate  table 
commonly  used  in  office  and  hospital  work.  There  is  some  advantage 
in  having  the  end  of  the  table  upon  which  the  pelvis  rests  about  three 
inches  higher  than  the  end  upon  which  the  head  rests. 

In  making  a  digital  or  conjoined  examination  with  the  patient 
lying  on  the  table,  the  examiner  stands  at  the  foot  of  the  table  facing 
the  patient,  and  passes  the  examining  hands  between  the  knees. 

The  Position  of  the  Patient. — Two  positions  are  in  common  use, 
the  dorsal  and  the  left  lateroprone  position  of  Sims.  The  knee- 
breast,  the  standing,  and  the  prone  positions  are  used  less  frequently ; 


DIAGNOSIS.  57 

each  has  advantages  peculiar  to  itself  and  to  the  conditions  under 
which  it  is  employed. 

Examination  of  Young  Girls. — The  first  examination  of  a  young 
girl  should  be  approached  with  reluctance,  and,  if  possible,  avoided. 
The  advantages  of  anaesthesia  from  the  standpoint  of  modesty  must 
be  apparent  to  all.  If  the  hymen  is  intact,  an  effort  should  be  made 
to  gain  the  necessary  information  by  a  conjoined  digital  exploration 
through  the  rectum,  the  palpating  hand  being  over  the  hypogastrium. 

Placing  the  Patient  on  the  Table. — The  clothing  about  the  waist 
having  been  loosened,  the  patient  steps  upon  a  chair  which  has  been 
placed  at  the  foot  of  the  table,  and,  the  skirts  having  been  raised 
behind,  sits  upon  the  extreme  end  of  the  table.  She  is  then  assisted 
to  lie  upon  her  back,  the  head,  not  the  shoulders,  being  supported  by 
a  pillow.  Before  lying  down  she  is  covered  with  a  sheet.  Under  the 
sheet,  and  without  exposure,  the  feet  are  lifted  from  the  chair  to  the 
table  and  placed  six  inches  apart ;  the  clothing  in  front  is  pushed 
above  the  knees  and  the  knees  are  widely  separated.  The  flexure  of 
the  thighs,  secured  by  placing  the  feet  on  the  table,  relaxes  the  abdom- 
inal muscles  and  facilitates  the  palpation.  The  edge  of  the  sheet  as 
it  falls  over  the  knees  is  parted  back  between  the  thighs  so  as  to 
expose  only  the  part  to  be  inspected — that  is,  the  vulva.  The  patient 
is  assured  that  she  is  neither  to  be  hurt  nor  unduly  exposed.  She  is 
now  ready  for : 

1.  Inspection. 

2.  Digital  examination  of  the  vagina  and  rectum. 

3.  Conjoined  examination. 

4.  Percussion,  palpation,  and  auscultation. 

5.  Mensuration. 

6.  Instrumental  examination. 

1.  Inspection. 

General  inspection  of  the  Tvhole  patient  is  not  only  essential  for 
careful  general  diagnosis,  but  it  is  also  important  to  inspect  the 
external  genitals  as  a  forewarning  against  possible  inoculation  of  the 
examining  finger  with  venereal  or  other  infection.  Some  historic 
cases  there  are  of  surgeons  who  have  gone  to  their  death  from  this 
cause.  The  writer  is  acquainted  with  not  less  than  twenty  phy- 
sicians who  have  contracted  syphilis,  some  of  them  fatal  syphilis, 
through  digital  touch.  Any  abrasion  on  the  hand  should  be  protected 
with  a  finger-cot  or  a  collodion  and  cotton  dressing  :  a  very  thin  layer 
of  cotton  is  placed  over  the  abrasion  before  the  collodion  is  applied. 
One  should  look  for  lacerations,  scars,  and  other  evidences  of  parturi- 
tion, vulvitis,  tumors,  urethral  caruncles,  urethritis,  eruptions,  hemor- 
rhoids, anal  fissure,  fistula  in  ano,  pin-worms,  eczema,  oedema,  cystocele, 
rectocele,  ulcers,  inflammation  of  Skene's  glands,  and  other  anomalies, 
and  should  note  the  calibre  and  elasticity  of  the  vulvar  orifice. 
Is  the  clitoris  enlarged  or  imprisoned  under  an  adherent  prepuce? 
Such  adhesions  may  give  rise  to  pronounced  reflex  disorders.  If  the 
vulva  is  that  of  a  virgin,  it  is  apt  to  be  small,  with  the  hymen  perfor- 
ated only  by  one  or  more  small  openings.  The  absence  of  such  a  hv- 
raen,  however,  is  neither  proof  nor  even  strong  evidence  of  unchastitv. 


58  GENERAL  PRINCIPLES. 

The  virgin  labia  minora  are  small,  firm,  double  folds  of  skin.  If 
they  are  long,  loose,  and  flabby,  and  especially  if  the  vulvar  orifice  is 
patulous,  the  indications  are  that  the  woman  has  had  one  or  more  chil- 
dren, or  has  had  much  treatment,  or  has  practised  self-abuse,  or  has 
been  the  subject  of  some  other  mechanical  interference. 

Inspection,  however,  is  not  limited  to  the  reproductive  organs  nor 
to  external  parts ;  it  may  extend  through'  the  aid  of  the  speculum  to 
the  vagina,  the  interior  of  the  bladder,  the  urethra,  the  rectum,  and, 
by  abdominal  section,  to  the  interior  of  the  abdomen  and  pelvis.  The 
surface  of  the  abdomen  is  also  open  to  visual  examination,  and  by  its 
enlargement  and  contour  may  disclose  the  presence  or  character  of  a 
tumor  or  ascitic  accumulation. 

2.  Digital  Examination. 

Left-hand  Method. — The  advantage  of  the  left  index-finger  for 
digital  touch  in  preference  to  the  right  was  demonstrated  and  its  use 
popularized  by  Marion  Sims.  The  great  superiority  of  the  left-hand 
method  is  acknowledged  usually  by  those  who  have  accustomed  them- 
selves to  both.  The  following  are  some  of  the  reasons  for  this  supe- 
riority :  1.  The  tactile  sense  of  the  left  finger  is  educated  more  easily. 
2.  Its  palmar  surface  more  readily  comes  in  close  relations  with  the 
left  side  of  the  pelvis,  and  disease  is  more  frequent  on  the  left  than  on 
the  riglit  side.  3.  The  stronger  right  hand  is  reserved  for  external 
palpation.  4.  The  right  hand  is  left  free  to  pass  the  probe  or  sound 
or  to  manipulate  any  instrument.  One  finger  usually  will  gain  as 
much  inform.ation  as  two.  The  introduction  of  two  fingers,  except  in 
a  capacious  vagina,  is  painful.  Two  fingers  may,  however,  sometimes 
be  of  use  in  the  examination  of  tumors. 

Lightness  of  Touch. — The  manner  of  digital  touch  has  been  well 
described  by  Emmet  as  follows  :  "  When  the  sense  of  touch  has  been 
cultivated,  it  yields  more  information  upon  which  to  base  a  diagnosis 
than  can  be  gained  by  the  eye  alone,  even  when  used  under  equally 
favorable  circumstances.  Therefore  the  digital  examination  should 
always  be  thoroughly  and  systematically  made.  It  is  all-essential  to 
possess  a  knowledge  of  departures  from  a  healthy  condition.  The 
lighter  the  touch  the  more  acute  it  will  be,  and  the  more  clearly  will 
it  appreciate  slight  changes.  It  is,  indeed,  remarkable  how  indi- 
viduals vary  in  their  method  of  making  examinations.  One  will  pro- 
ceed with  as  much  vigor  as  if  he  were  boring  a  hole,  and  finds  little 
more  than  the  cervix,  Avhich  feels  like  an  obstruction  in  his  way.  He 
gains  no  information  of  importance,  and  inflicts  unnecessary  pain.^ 
Another  will  pass  his  finger  lightly  over  every  portion  of  the  vagina, 
and,  without  having  caused  any  pain,  quickly  ascertain  enough  to 
enable  him  fully  to  understand  the  case." 

Distension  of  the  Bladder  During  Examination. — In  the  chap- 
ter on  Displacements  of  the  Uterus  stress  is  laid  on  the  great  import- 
ance of  having  the  bladder  and  rectum  empty  when  digital  examina- 
tions are  being  made.  The  author's  experience  has  shown  that  when 
palpation  of  the  ovaries  is  desired,  they  sometimes  are  forced  down 
within   reach   of  digital   touch  with   startling  distinctness  when   the 


DIAGNOSIS. 


59 


bladder  is  distended  witli  fluid.  The  required  distension  may  Ue 
secured  by  throwing  in  sterile  salt  water  1  per  cent,  tlirough  a  catheter 
attached  to  a  fountain  syringe. 

Conduct  of  Digital  Examination. — The  hand  having  been  washed 
carefully,  the  left  index-finger  is  lubricated  with  glycerin,  mild 
castile  soa]),  or  glycerin  emollient  (Chapter  II.),  and  then  slowly  in- 
troduced, the  palmar  surface  being  directed  downward  so  as  to  depress 
the  perineum  toward  the  rectum  ;  it  notes  the  rigidity  of  the  perineum, 

Figure  10. 


Digital  eversion  ot  the  anus. 

the  presence,  absence,  or  consistence  of  the  feces  in  the  rectum,  the 
calibre  and  relaxation  or  rigidity  of  the  vagina,  and  the  condition  of 
the  sacrum  and  coccyx.  The  palmar  surface  of  the  finger  now  is 
directed  alternately  toward  the  lateral  and  the  anterior  portions  of  the 
pelvis  and  swept  around  the  cervix.  The  direction,  size,  form,  and 
consistence  of  the  cervix,  the  calibre  and  form  of  the  os  externum, 
and  the  presence  or  absence  of  laceration  become  apparent.     The  right 


60  GENERAL  PRINCIPLES. 

hand  now  is  placed  over  the  abdomen  behind  the  pubes,  and  the  in- 
quiry continued  by  conjoined  examination.  Irritation  of  the  clitoris 
may  give  rise  to  sexual  excitement ;  hence  the  examining  hand  should 
be  kept  well  away  from  it. 

Digital  examination  with  the  patient  standing  has  some  value  as  a 
means  of  diagnosis  in  uterine  displacements.  The  examination  may 
be  made  with  the  woman  in  the  left  lateroprone  position,  but  this 
position  is  reserved  rather  for  speculum  examinations  and  operations. 

Eversion  of  the  Anus,  as  shown  in  Figure  10,  enables  the  exam- 
iner to  judge  of  the  condition  of  the  lower  part  of  the  rectum  and  anus, 
and  may  be  done  either  in  the  dorsal  or  lateral  position. 

3.  Conjoined  Examination. 

Conjoined  Vaginal  Examination,  often  called  bimanual  palpa- 
tion, is  designed  to  bring  within  the  range  of  touch  all  the  pelvic 
organs.  These  organs,  one  by  one,  in  some  cases  are  lifted  forward, 
by  the  finger  or  fingers  in  the  vagina,  toward  the  anterior  abdominal 
wall,  where  they  can  be  palpated  by  the  right  hand  pressed  down 
behind  the  pubes.  Usually,  however,  the  right  hand  forces  them 
down  to  a  point  where  they  may  be  examined  readily  by  digital 
touch.  The  latter  method  is  usually  preferable,  because  the  applica- 
tion of  much  force  in  the  vaginal  or  rectal  touch  may  be  harmful  to 
the  patient  or  may  impair  the  tactile  sense  of  the  finger.  A  combi- 
nation of  both  methods  is  desirable.  The  necessary  amount  of  force 
will  vary  with  the  tolerance  of  ihe  patient  and  the  skill  of  the  exam- 
iner. The  reach  of  the  examining  finger  is  increased  materially  by 
forcing  the  elastic  perineum  backward  toward  the  interior  of  the 
pelvis. 

Bimanual  examination,  to  be  effective,  requires  long  practice.  The 
beginner  is,  first,  to  bring  the  organs  properly  between  the  two 
hands ;  second,  to  appreciate  what  may  be  within  his  reach.  Should 
the  thickness  or  rigidity  of  the  abdominal  walls  prevent  the  downward 
pressure  of  the  hand  behind  the  pubes,  the  resistance  may  be  overcome 
by  continuous  firm  pressure,  or  by  successive  short  strokes  of  vibra- 
tory massage,  or  by  circular  massage.  The  difficulty  is  often  the 
result  of  the  patient's  nervousness.  The  examiner  should,  therefore, 
avoid  sudden  movements  in  manipulation.  A  deep  inspiration  by  the 
patient,  followed  by  a  quick  expiration,  while  steady  pressure  is  being 
made,  may  momentarily  relax  the  muscles,  and  thereby  afford  the 
examiner  an  opportunity  of  rapidly  palpating  the  pelvic  organs.  An 
examiner  of  acute  touch  and  quick  ])erception  will  gain  sometimes  in- 
stantaneously the  required  information  in  this  way.  During  the  exam- 
ination the  patient  should  keep  the  mouth  open. 

If  the  uterus  and  its  appendages  are  sensitive,  or  fixed  by  adhesions, 
the  attempt  to  force  them  up  toward  the  outside  hand  may  be  futile  or 
even  dangerous.  Deep  palpation  behind  the  pubes  is  then  necessary. 
One  should  remember,  however,  that  even  a  little  force  injudiciously 
applied  by  either  hand  may  rupture  a  pus-pocket  or  tube,  and  thereby 
lead  to  serious  results. 


DIAGNOSIS. 


61 


Bimanual  palpation  enables  one  to  judge  of  the  following  eondi- 
tions :  the  size,  form,  location,  position,  consistence,  and  mobility  of 
the  uterus,  the  presence  or  absence  of  a  pelvic  tumor.  If  the  uterus 
is  displaced,  is  it  replaceable,  or  is  it  bound  by  adhesions,  and  there- 
fore irreplaceable  ?  If  there  is  a  tumor  in  the  pelvis,  is  it  a  neoplasm 
or  an  inflammatory  swelling  ?     If  the  former,  it  is  not  sensitive ;  if 

Figure  11. 


Vaginal  touch,  conjoined  examination. 


the  latter,  it  is  tender  on  pressure.  Is  it  connected  with  the  uterus, 
or  the  Fallopian  tube,  or  the  broad  ligament,  or  the  ovary  ?  Is  it 
cystic  or  solid,  malignant  or  benign?  Does  it  originate  in  the  pelvis, 
or  in  the  abdominal  cavity,  and,  above  all,  is  it  possibly  due  to  preg- 
nancy? These  questions  will  come  up  again  under  the  diagnosis  of 
special  disorders. 


62 


GENER  A  L  PR  INCIPLES. 


Conjoined  Rectal  Examination. — Conjoined  examination  by  rec- 
tal instead  of  vaginal  touch  may  confirm,  disprove,  or  supplement  the 
previous  observations  and  impressions.  Figure  12.  Rectal  touch, 
whether  digital  or  conjoined,  may  be  impeded  by  coils  of  intestine  in 
the  pelvis  interposed  between  the  finger  and  the  viscera  to  be  palpated. 


Figure  12. 


Rectal  touch,  conjoined  examination.  In  examining  at  the  yjatient's  house  without  re- 
moving tlie  coat  or  loosening  the  starclied  shirt-cuft's,  tlie  examiner  may  yjush  them  up  over 
the  wrists  and  retain  them  there  by  pulling  down  the  sleeves  of  the  undershirt,  and  turning 
them  back  over  the  cuffs,  as  shown  in  this  illustration. 


This  may  be  avoided  l)y  a  simple  device  of  Kelly's  :  "  The  rectum  and 
bladder  are  first  evacuated,  the  patient  is  put  in  the  knee-chest  j^osture, 
and  a  speculum  is  introduced  into  the  rectum.  This  lets  in  a  large 
amount  of  air.  and  the  bowel  balloons  out  and  applies  itself  Ijroadly 
over  the  sacral  hollow  and  the  posterior   surfaces  of  the   uterus  and 


DIAGNOSIS. 


63 


left  broad  ligament,  and  in  a  minute  or  two  the  small  intestine  falls 
away  into  the  upper  abdomen.  The  patient  must  then  be  turned  on 
her  back,  care  being  taken  to  keep  the  pelvis  constantly  higher  than 
the  rest  of  the  abdomen,  so  as  not  to  let  the  intestines  gravitate  again 
into  the  pelvic  cavity.  On  making  the  bimanual  examination  the 
pelvic  viscera  are  felt  with  startling  distinctness,  the  rectal  finger 
enters  a  large  air-cavity  no  longer  impeded  by  the  mucous  folds ;  the 

FIGURE    13. 


Conjoined  rectovaginal  palpation. 

opening  from  the  lower  into  the  upper  rectum  is  readily  found  ;  and 
the  posterior  surface  of  the  uterus  and  the  ovaries  and  tubes  feel  as  if 
skeletonized  in  the  pelvis.  They  lie  so  clearly  exposed  to  touch  that 
their  minuter  surface-peculiarities,  fissures  and  elevations  and  varia- 
tions in  consistence  can  be  detected."  This  peculiar  ballooning  of  the 
rectum  is  observed  often  in  obstruction  and  paresis  of  the  bowel,  and 
may  be  felt  with  the  patient  in  the  dorsal  position  without  recourse  to 
the  device  of  Kelly. 


64 


GENERAL  PRINCIPLES. 


Conjoined  Rectovaginal  Examination  is  made  with  the  left 
index-finger  in  the  rectum,  the  thumb  in  the  vagina,  and  the  right 
hand  behind  the  pubes.  See  Figure  13.  In  this  way  the  perineum 
is  pushed  w^ell  up  toward  the  interior  of  the  pelvis.  If  the  abdom- 
inal wall  is  thin  and  relaxed,  the  various  pelvic  organs,  when  forced 
down  by  the  hand  behind  the  pubes,  may  be  picked  up,  so  to  speak, 
between  the  thumb  and  finger  and  definitely  palpated. 

Traction  as  an  Aid  to  Conjoined  Examination. — Palpation  of 
the  pelvic  organs,  especially  the  ovaries  and  Fallopian  tubes,  is  facili- 

FlGURE    14. 


Uterus  drawn  down  bv  means  of  tooth-forceps  to  facilitate  manual  examination  or  replace- 
ment :  (I,  rubber  finger-cot  on  finger  ;  b,  rubber  finger-cot  rolled  up. 


tated  often  by  drawing  the  uterus  toward  the  vulva  by  means  of  a 
uterine  tenaculum  or  small  tooth-forceps.  Figure  14.  During  the 
palpation  these  instruments  may,  if  necessary,  be  held  by  an  assistant. 
Anaesthesia. — Failure  to  engage  the  uterus  between  the  hands  in 
conjoined  examination  may  be  due  to  fixed  retroversion  or  to  rigidity 
of  the  abdominal  muscles,  or  to  sensitiveness  of  the  parts  under  exam- 
ination, or  to  the  nervousness  of  the  patient.  Intelligent  treatment 
may  be  impossible  under  these  conditions  without  anaesthesia.     The 


DIAGNOSIS. 


65 


accurate  and  adequate  diagnosis  thus  obtained  lessens  the  number 
of  exploratory  incisions  and  unnecessary  operations,  prevents  a  vast 
amount  of  indefinite  injurious  local  treatment,  and  substitutes  rational 
medicine  and  surgery. 

The  Roots  of  the  Sciatic  Nerve  maybe  palpated  through  the 
rectum,  as  shown  in  Figure  15;  such  an  examination  sometimes  will 
reveal  the  source  of  obscure  pelvic  pain  which  has  previously  been  at- 
tributed to  ovarian  or  uterine  origin.     The  patient  must  be  examined 

Figure  15. 


Palpation  of  the  roots  of  the  sciatic  nerve  by  rectal  touch. 


Without  anapsthesia,  and  as  the  fingers  are  drawn  over  the  tender  cord 
a  cry  of  pain  will  be  elicited. 

Conjoined  Examination  with  the  Sound.— One  may  be  unable 
by  touch  to  decide  whether  a  tumor  is  of  uterine  or  extra-uterine 
origin.  The  uterus  may  then  be  immobilized  bv  the  sound  passed 
into  the  uterine  canal  and  held  immovable  by  the'  hand  of  an  assist- 
ant, or  the  uterus  may  be  steadied  by  a  tooth-forceps  or  tenaculum 
attached  to  the  cervix.  The  examiner  then  mav  determine  whether 
the  tumor  moves  with  the  uterus  or  independently  of  it.  In  case  of 
a  uterine  tumor  with  a  long  pedicle,  or  of  an  "extra-uterine  tumor 
adherent  to  the  uterus,  the  test  may  fail. 


ee 


GENERAL  PRINCIPLES. 


The  necessity  of  conjoined  examination  is  apparent  in  Figures  16 
and  18.  Vaginal  touch  alone  in  Figure  16,  A,  which  represents  a 
myomatous  uterus,  would  give  the  same  impression  as  in  Figure  16, 
B,  which  shows  a  retroflexed  uterus.  Conjoined  examination  in  Fig- 
ure 16,  A  and  B,  would  establish  the  fact  of  myoma  in  one  case  and 
the  retroflexion  in  the  other.     The  exact  direction  of  the  uterine  canal 

Figure  16. 


A.  Myoma  in  the  posteiior  wall  of  the  uterus. 


B.  Retroflexion  of  the  uterus. 


and  the  relations  of  the  uterus  to  the  tumor  might  in  such  cases  be 
learned  by  passing  the  probe  or  the  sound. 


4.  Percussion,  Palpation,  and  Auscultation. 

These  means  of  diagnosis  are  applicable  to  the  differentiation  of 
abdominal  tumors  and  enlargements  of  inflammatory  origin,  especially 
pregnancy.  The  inquiry  should  include  both  gynecological  disorders 
and  others  that  simulate  or  complicate  them.  Among  the  latter  may 
especially  be  mentioned  appendicitis,  a  condition  frequently  associated 
with  infection  of  the  uterine  appendages,  especially  on  the  right  side. 
One  who  has  not  systematically  included  the  renal  organs  in  his  ex- 
amination will  be  astounded  at  the  revelations  of  such  investigations. 
Hydronephrosis,  abscess  and  stone  in  the  kidney,  tubercular  kidney, 
loose  and  floating  kidney,  and  stricture  of  the  ureter  are  among  the  path- 
ological conditions  commonly  overlooked.    The  mere  mention  of  intesti- 


DIAGNOSIS. 


67 


nal,  gastric,  splenic,  and  hepatic  disorders  should  be  sufficient.  Kelax- 
ation  of  the  abdominal  walls,  with  consequent  falling  of  the  intestines 
— enteroptosis — associated  also  with  the  falling  of  other  abdominal 
organs,  especially  the  stomach  and  kidney,  is  a  frequent  and  unrecog- 
nized cause  of  abdominal  and  pelvic  disorders.  See  Pendulous  Abdo- 
men and  Displacement  of  Abdominal  Viscera,  at  the  close  of  Chapter 
XLIV. 

5.  Mensuration. 

Mensuration  is  important  in  the  examination  of  new  growths  and 
other  lesions  causing  abdominal  enlargement,  and  will  be  considered 

Fig  TIKE  17. 


Conjoined  examination  of  a  solid  tumor  of  the  uterus.    Here  the  tumor-mass  is  palpably  a 

part  of  the  uterus. 


further  in  connection  with  the  special  diagnosis  of  these  disorders. 
The  measurements  of  the  bony  pelvis  frequently  have  great  signifi- 
cance, not  only  from  the  obstetrical,  but  also,  especially  in  the  matter 
of  displacements  and  malformations,  from  the  gynecological  point  of 
view.  The  reader  is  referred  for  pelvic  mensuration  to  the  literature 
of  obstetrics. 


68  GENERAL  PRINCIPLES. 

6.  Instrumental  Examinations. 

As  already  stated,  the  development  of  modern  gynecology  has  been 
made  possible  by  the  use  of  instruments  of  precision  designed  to  in- 
crease the  power  or  widen  the  range  of  the  senses.  The  diagnostic 
methods  already  described  usually  will  fiu-nish  the  groundwork  for 

FiGUEE   18. 


Conjoined  examination  of  a  cystic  tumor  of  the  oyary.  The  hands  of  an  assistant  are  mov- 
ing the  tumor  from,  side  to  side. "  The  uterus  does  not  move  with  the  cyst.  The  hands  of  the 
examiner  are  separating-  the  cyst  from  the  uterus.  The  separation  of  the  cyst  from  the  uterus 
and  the  independent  movement  of  it  demonstrate  it  to  be  of  extra-uterine  origin. 

diagnosis.  Instrumental  examination  may  supplement  and  verify  con- 
clusions already  foreshadowed.  Some  of  the  instruments  used  for 
diagnostic  purposes  are  : 

The  exploratory  needle  and  aspirator, 

The  stethoscope, 

The  microscope, 

The  urethroscope  and  cystoscope. 
The  Speculum. — The  choice  of  the  speculum  is  simplified  by  the 
statement  that  of  the  innumerable  varieties  only  two  require  serious 
consideration,  and  that  these  two  act  on  the  same  principle — as  peri- 
neal retractors.     Thev  are  : 


i.  The  speculum,  5. 

2.  The  sound  and  probe,  6. 

3.  The  dilator,  7. 

4.  The  curette,  8. 


DIAGNOSIS. 


69 


Sims'  speculum. 

Simon's  speculum. 
Sims'  speculum  is  an  instrument  of  great  simplicity  and  effective- 
ness. The  objection,  sometimes  urged,  that  the  efficient  use  of  it  re- 
quires long  practice,  is  a  mistake.  Whoever  once  masters  the  simple 
principles  of  the  left  lateroprone  position  will  have  little  or  no  diffi- 
culty. The  failure  to  appreciate  the  mechanical  relations  of  this  posi- 
tion to  Sims'  speculum  will  explain  most  of  the  disappointments  result- 
ing from  its  use.     Another  alleged  disadvantage  of  Sims'  speculum  is 

FiGUKE    19. 


Percussion  in  the  diagnosis  of  abdominal  enlargement  due  to  accumulation  of  ascitic  fluid. 
Intestines  float  to  the  surface  of  the  fluid.  Kesonaiue  over  intestines.  Dulness  in  flanks  below 
level  of  fluid.  Change  in  position  of  the  patient  would  make  corresponding  change  in  areas  of 
resonance  and  dulness— that  is,  the  higher  parts  would  give  resonance,  and  thie  lower  parts 
dulness. 

the  necessity  of  a  trained  assistant  to  hold  it.  If  the  examiner  himself 
knows  how  the  instrument  should  be  held,  the  assistant  need  not  be 
trained.  In  gynecological  examinations  the  presence  of  a  third  person 
is,  for  obvious  reasons,  an  advantage.  Examinations  at  the  patient's 
house  may  be  made  usually  with  the  assistance  of  some  member  of  the 
family.  The  physician  who  has  a  large  office  practice  should  have 
the  assistance  of  an  office  attendant ;  or  if  this  is  impracticable,  a  modi- 
fied self-retaining  Sims'  speculum  may  be  used. 


70 


GENERAL  PRINCIPLES. 


Thomas,  after  long  experience  with  other  instruments,  makes  a 
statement  something  like  this  :  "  Learn  the  use  of  Sims'  speculum, 
persevere  in  the  method  for  three  months,  and  you  will  never  give  it 
up."  Emmet,  whose  experience  with  the  instrument  is,  perhaps, 
greater  than  that  of  any  other,  says  :  "  This  instrument  is  so  simple 
in  design,  and  so  perfectly  does  it  fulfil  every  requirement,  that  it  will 
probably  never  be  superseded. 

The  Self-retaining  Sims'  Speculum. — Modifications  of  Sims'  specu- 
lum to  make  it  self-retaining  have  been  devised  by  Emmet,  Cleveland, 
and  others.  They  are  all  inferior  to  the  original  Sims'  instrument, 
but  superior  to  the  multiform  cylindrical  and  bivalve  instruments. 
Cleveland's  self-retaining  speculum  is  one  of  the  best  examples  of  its 
kind. 

Thf  Left  Lateropeone  Position. — In  order  to  appreciate  the 
action  of  Sims'  speculum  it  becomes  necessary  to  study  the  effect  of 

Figure  20. 


Incorrect  representation  of  Sims'  left  lateroprone  position,  taken  from  a  standard  text-book. 


Sims'  lateroprone  position  upon  the  pelvic  organs.  Like  the  knee- 
breast  position,  of  which  it  is  a  modification,  it  causes  the  vagina  to  fill 
with  air,  and  the  anterior  and  posterior  vaginal  walls — or,  to  speak 
more  comprehensively,  the  pubic  and  sacral  segments  of  the  pelvic 
floor — to  separate.  The  speculum  then  exaggerates  the  effect  of  this 
position  by  hooking  or  drawing  back  the  perineum,  which  exposes 
almost  the  entire  surface  of  the  widely  opened  vagina,  and  causes  the 
cervix  to  be  drawn  somewhat  toward  the  vulva. 

Two  requirements  are  essential  to  the  successful  use  of  Sims'  spec- 
ulum— correct  position  of  the  patient  and  proper  holding  of  the 
instrument.  The  patient  is  to  be  placed  on  the  left  side,  the  hips 
being  over  the  left-hand  corner  of  that  end  of  the  table  which  is 
toward  the  operator ;  the  knees  are  to  be  drawn  up  toward  the  abdo- 


DIAGNOSIS. 


71 


men,  and  the  right  thigh  flexed  slightly  more  than  the  left.  The 
patient's  left  arm  rests  behind  her  on  the  table.  This  permits  the 
right  shoulder  to  be  thrown  forward  and  depressed  toward  the  right 
side  of  the  table,  so  that  the  position  becomes  lateroprone — that  is, 
lateral  and  slightly  prone  at  the  hips,  and  almost  wholly  prone  at  the 
shoulders.  The  left  side  of  the  head  rests  upon  the  table,  the  face 
looking  to  the  right.  The  right  arm  hangs  over  the  right  side  of  the 
table,  and  the  long  axis  of  the  trunk  extends  obliquely  across  the 
table  from  left  to  right. 

Figure  21. 


CORRECT     S1M5     POSITION 


Correct  lateroprone  position. 


The  reader  is  ursed  to  study  tliis  Figure  in  connection  witli  thp 
text. 


The  steps  of  an  examination  with  Sims'  speculum  are  these  : 

1.  Place  the  patient,  the  waist  clothing  being  loose,  in  Sims'  left 
lateroprone  position,  the  head,  not  the  shoulders,  supported  by  a  very 
thin  pillow. 

2.  Protect  the  buttocks  with  the  towels. 

3.  Let  the  nurse  lift  up  the  right  labium. 

4.  Introduce  one  blade  of  the  speculum  and  place  the  other  in  the 
nurse's  hand. 

5.  With  the  depressor  in  the  right  hand,  push  the  anterior  vaginal 
wall  forward  until  the  cervix  uteri  comes  into  full  view. 

6.  With  a  wad  of  absorbent  cotton  in  the  grasp  of  the  uterine  dress- 
ing-forceps, wipe  out  any  secretion  in  the  vagina  that  may  be  found. 


72 


GENERAL  PRINCIPLES. 


7.  If  the  sound  is  to  be  passed  or  the  uterus  otherwise  instrument- 
ally  examined,  change  the  depressor  to  the  left  hand  and  use  the  right 
for  this  purpose.     Instead  of  using  the  depressor  during  the  instru- 


FlQTJRE  22. 


Sims'  speculum  and  depressor  in  use :  a,  depressor;  6,  speculum:  c,  Emmet's  dressing-for- 
ceps :  d,  Emmet's  uterine  tenaculum.  The  upper  hand  shows  the  position  of  the  examiner's 
fingers  in  the  introduction  of  the  speculum.  These  instruments  are  in  general  use  for  exam- 
ination by  the  Sims  method.    Two  or  more  uterine  tenacula  are  required. 

mentation  of  the  uterus,  it  is  often  desirable  to  steady  the  cervix  with 
the  tenaculum  or  tenaculum  forceps.     Figure  23. 

In  many  cases  the  vagina  balloons  with  the  inrush  of  air,  and  the 
whole  field  comes  into  full  view  without  the  use  of  the  depressor. 


DIAGNOSIS. 


73 


The  patient  is  now  ready  for :  1,  inspection  of  the  entire  vaginal  sur- 
face ;  2,  instrumental  examination  of  the  interior  of  the  uterus. 

Vaginitis,  ulcers,  laceration  of  the  cervix,  erosion,  cystic  degen- 
eration, vaginal  cicatrices,  traumatisms,  vaginal  fistulae,  carcinoma  of 
the  cervix,  and  other  new  growths  if  present  may  now  be  observed. 


Figure  23. 


Examination  with  Sims'  speculum.  The  towels  ordinarily  used  to  cover  parts  around  the 
vulva  are  omitted  in  order  to  show  the  exact  position  of  the  pe'lvis  and  thighs.  Passage  of  probe 
or  curette  ;  cervix  steadied  by  vulsellum. 

Pathological  discharges  may  be  taken  for  microscopical  examination, 
and  their  source,  whether  from  tlie  uterus  or  the  vagina,  may  be 
observed. 

Simon's  Speculum,  sh.own  in  Figure  24,  is  a  perineal  retractor  simi- 
lar  to    Sims'    but  with    shorter  and  flatter  blades,  which  are   made 


74 


GENERAL  PRINCIPLES. 


of  different  shapes  and  sizes.  It  differs  from  Sims'  chiefly  in  the 
manner  of  use,  which  requires  the  patient  to  be  on  the  back,  and  the 
thighs  to  be  flexed  in  the  lithotomy  position.     An  objection  to  this 


Figure  24. 


uterus  exposed  by  Simon's  speculum.  Dorsal  position.  Cervix  uteri  steadied  bv  tenaculum. 
Uterine  canal  being  measured  by  Peaslee's  sound:  n,  uterine  tenaculum:  &,  Peaslee's  sound: 
c,  silver  probe ;  and  d,  Simon's  speculum  are  reduced  to  about  one-half  the  ordinary  size. 

instrument  is  that  the  vesicovaginal  walls  are  liable  to  fall  toward  the 
speculum,  and  the  lateral  walls  fall  together  in  sucli  a  way  as  to 
obscure  the  field  of  operation.     To  obviate  this  difficulty  one  may  use 


DIAGNOSIS. 


(0 


a  smaller  though  similar  retractor  which  acts  in  the  opposite  direc- 
tion, like  the  anterior  blade  of  the  bivalve  speculum,  and,  if  necessary, 
lateral  depressors  on  either  side.  All  of  these  instruments  are  more 
or  less  in  the  operator's  way ;  besides,  the  introduction  of  the  sound, 
curette,  or  other  instruments  to  the  interior  of  the  uterus  is  more  dif- 
ficult in  the  dorsal  than  in  the  Sims  position  ;  moreover,  if  the  organ 
is  anteverted  or  anteflexed,  the  instrument  is  especially  liable  to  be 
arrested  at  some  point  on  the  posterior  wall  of  the  cervix  or  at  the 
internal  os,  and  refuse  to  pass  further.  Simon's  speculum  is  held 
less  easily,  and  requires  more  assistants,  more  attachments  and 
depressors,  than  Sims' ;  it  gives  less  light  and  space,  and  for  general 
diagnostic  and  surgical  use,  therefore,  should  seldom  have  the  pref- 
erence over  the  Sims  instrument.      On  the  other  hand,  the  Simon 


FiGUKE  25. 


Sounds  of  Simpson  and  Sims  compared :  sections  of  full  size.    The  upper  sound  is  Sims'  :  the 

lower  Simpson's. 

instrument  is  preferable  for  vaginal  hysterectomy  and  many  other 
operations  involving  vaginal  section. 

The  Probe  and  Sound  have  been  mentioned  in  connection  with 
conjoined  palpation  as  a  means  of  diagnosis  in  tumors.  In  some 
cases  the  sound,  and  especially  the  probe,  may  be  difficult  or  impossible 
to  pass  in  the  dorsal  position,  but  may  readily  be  passed  with  the  aid 
of  Sims'  speculum  in  the  lateral  position. 

To  Pass  the  Probe  or  Sound,  the  Patient  being  in  the  Dorsal  Posi- 
tion, without  a  speculum,  first  introduce  the  left  index-finger  to  the  os 
externum,  then,  on  the  finger  as  a  guide,  introduce  the  instrument  into 
the  OS  and  let  it  find  its  own  way,  judiciously  aided  by  slight  force, 
to  the  fundus. 

To  Pass  the  Sound  or  Probe  through  the  Speculum,  first  bring  the 
cervix  into  view,  seize  it  with  a  uterine  tenaculum  or  with  a  small  vul- 
sellum  forceps,  gently  draw  it  toward  the  vulva,  and  pass  the  instru- 
ment, having  bent  it  before  introduction  to  conform,  as  nearly  as  the 
surgeon  can  judge,  to  the  direction  of  the  canal.     The  forward  trac- 


76 


GENERAL  PRTNCIPLES. 


tion  of  the  uterus  greatly  facilitates  the  passage — in  fact,  is  sometimes 
essential. 

Dangers  of  the  Sound  and  Probe. — Numerous  cases  of  grave  infec- 
tion following  the  use  of  these  instruments  have  given  rise  to  an 
impression  that  they  are  dangerous.  The  risk,  however,  is  practically 
nothing  if  complete  asepsis  is  maintained.  Even  a  clean  instrument 
may  carry  infection  from  the  vagina  or  vulva ;  hence  the  necessity  of 
thorough  asepsis  of  these  parts.  The  sound  without  asepsis  is  more 
objectionable  than  the  probe,  for  it  is  not  only  equally  liable  to  be  the 
carrier  of  sepsis,  but  is  more  liable  to  wound  the  sensitive  endome- 
trium, and  thereby  open  the  door  to  microbic  invasion.  The  passage 
of  the  fine  probe  is  usually  painless.  The  sound  in  a  sensitive, 
inflamed  uterus  may  be  intolerable. 

Figure  26. 


Passing  soujid ;  first  step :  patient  in  dorsal  position  without  speculum ;  point  of  sound  is 
guided  along  palmar  surface  of  left  index-finger  to  os  externum. 

The  diagnostic  value  of  the  sound  and  probe  is  sometimes  very 
great.  One  may,  for  example,  be  unable  to  locate  the  uterus  except 
by  the  direction  which  the  sound  takes.  The  tortuosity  of  the  canal, 
may  at  once  show  the  relations  of  a  myoma  to  the  uterus.  The  sen- 
sations imparted  to  the  hand  from  the  point  of  the  sound  will  some- 
times give  evidence  of  pathological  conditions  inside  the  uterus.  The 
length  of  the  canal  in  a  myomatous  uterus  is  increased,  but  not  mate- 
rially increased  by  the  presence  of  ovarian  and  other  extra-uterine 
tumors.  The  case,  however,  is  rather  exceptional  in  which  the  sound 
or  probe  is  a  necessary  means  of  diagnosis.  The  more  experience  one 
has,  the  more  educated  one's  touch,  the  less  one  will  need  to  use  these 
instruments  for  diagnostic  purposes. 


DIAGNOSIS.  77 

Uterine  Dilatation  may  be  accomplished  in  the  following  ways  : 

1.  By  graduated  bougies,  or  sounds,  after  the  method  of  dilatation 
of  the  male  urethra. 

2.  By  instruments  of  diverging  blades  constructed  on  the  principle 
of  the  glove-stretcher. 

3.  By  water  dilators. 

4.  By  tents. 

The  object  of  diagnostic  dilatation  is  to  open  the  endometrium  in 
order  that  by  means  of  the  curette  a  specimen  may  be  removed  for 
microscopical  examination,  or  in  order  that  the  finger  may  be  used  for 
intra-uterine  digital  touch.  Dilatation  is  required  more  frequently 
for  therapeutic  than  for  diagnostic  purposes.     The  technique  is  the 

Figure  27. 


■'  ■- \ 

v  -    .gjitf  jj^H 

^  ^ 

\'  _., 

'^^Mr 

r 

^"^^  "^ 

^ 

y 

— 

Passing  sound ;  second  step  :  patient  in  dorsal  position  without  speculum.  As  sound  passes  from 
OS  externum  to  fundus  index-finger  is  moved  from  os  externum  to  posterior  vaginal  fornix. 

same  for  diagnostic  as  for  therapeutic  dilatation.  See,  therefore,  a 
description  of  the  latter  in  Chapter  V.,  on  Minor  Operations. 

Diagnostic  Curettage. — The  object  of  diagnostic  curettage  is  to 
remove  enough  diseased  tissue  for  microscopical  or  other  examination. 
If  the  curette  is  small,  and  the  os  patulous,  curettage  is  sometimes 
possible  without  anaesthesia  or  previous  dilatation.  Usually,  however, 
the  procedure  requires  both.  Microscopical  examination  of  the  scrap- 
ings is  frequently  the  only  means  of  differentiation  between  hemor- 
rhagic endometritis,  the  remains  of  abortion,  post-abortum  endome- 
tritis, carcinoma,  and  sarcoma.  The  technique  of  curettage  is  described 
in  Chapter  V. 

The  Exploratory  Needle  and  Aspirator  have  the  same  diagnostic 
and  therapeutic  significance  in  gynecology  as  in  other  departments  of 
surgery — i.  e.,  the  removal  of  fluid.     The  contents,  for  example,  of  a 


78  GENERAL  PRINCIPLES. 

sactosalpinx,  a  renal  cyst,  a  pelvic  abscess,  or  an  ovarian  cyst  may  be 
removed  for  visual,  chemical,  or  microscopical  examination. 

The  uses  of  the  stethoscope  and  microscope  will,  as  the  occasion 
requires,  be  mentioned  in  the  diagnosis  of  special  diseases. 

Examination  of  the  Anus  and  Rectum. 

Rectal  touch  and  eversion  of  the  anus  by  means  of  the  finger  in 
the  vagina  have  been  noticed  in  the  earlier  pages  of  this  chapter. 
Numerous  specula  have  been  devised  for  inspection  of  the  interior 
of  the  rectum.  For  examination  of  the  lower  part  of  the  rectum, 
Sims'  speculum  is  immeasurably  superior  to  all  others.  It  is  used 
for  this  purpose  the  same  as  for  vaginal  examination — i.  e.,  with  the 
patient  in  the  left  lateroprone  position. 

The  Proctoscope  and  Si^oidoscope. — The  frequent  association 
or  confusion  of  rectal  disease  with  the  diseases  of  women  may  render 
necessary  the  inspection  of  the  upper  part  of  the  rectum  ;  for  this 
purpose  Kelly  uses  a  tubular  speculum,  called  a  proctoscope,  about  1 
inch  in  diameter  and  8  inches  long.  For  still  higher  examinations 
he  uses  the  sigmoidoscope,  of  the  same  diameter,  but  14  inches  long. 
The  patient  is  examined  in  the  knee-breast  position,  and  the  light  is 
thrown  in  by  a  head-mirror.  Examination  through  these  instruments 
is  most  satisfactory. 

Examination  of  the  Urinary  Organs. 

The  means  of  examination  are  these : 

1.  Urinalysis. 

2.  Palpation,  percussion,  and  inspection. 

3.  Urethroscopy. 

4.  Cystoscopy  and  ureteral  exploration  and  catheterization. 

5.  Segregation  of  urine. 

1.  Urinalysis. — The  study  of  the  urine  involves,  first,  chemical 
examination ;  second,  microscopical  examination. 

The  chemical  examination  will  show  changes  in  the  proportion  or 
quality  of  solids,  and  will  suggest  the  possible  relation  of  these 
changes  to  pathological  conditions  and  functional  disorders.  For 
example,  decrease  in  urea  may  signify  nephritis.  Abundance  of  uric 
acid  would  indicate  that  more  exercise  and  less  nitrogenous  food 
should  be  taken.  Excessive  acidity  would  account  for  irritation  of 
the  bladder  and  frequent  urination.  Microscopical  examination  may 
locate  the  existence  of  disease  in  either  the  kidney,  ureter,  or  bladder. 

2.  Palpation,  Percussion,  and  Inspection. — Palpation  and  per- 
cussion over  the  hypogastrium  may  give  strong  evidence  of  distention 
of  the  bladder ;  further  evidence  would  be  the  bulging  of  the  anterior 
vaginal  wall  toward  the  vulva,  and  constant  dribbling  of  urine.  The 
evacuation  of  a  large  quantity  of  urine  through  the  catheter  would  be 
proof. 

Palpation  with  conjoined  examination  may  show  a  tumor  in  the 
bladder.     Vaginal  and  rectal  touch  also  may  give  much  information 


DIAGNOSIS. 


79 


relative  to  the  urethra,  bladder,  and  ureter.  Vaginal  touch  will 
enable  one  to  judge  of  sensitiveness  in  the  urethra  and  neck  of  the 
bladder.     In  the  anterior  wall   of   the  vagina  to  either  side  of  the 


Figure  28. 


Proctoscopy:  proctoscope  8  inches  long  and  1  inch  wide.  The  sigmoidoscope  is  the  same 
except  in  length,  which  is  1-1  inches.  The  instrument  is  provided  with  an  obturator  (shown 
detached  in  the  lower  part  of  the  Figure) ;  it  is  in  nearly  all  respects  except  size  identical  with 
the  cylindrical  cystoscope. 


median  line  the  ureter  may  often  be  felt  as  it  passes  in  a  posterior 
and  lateral  direction  on  either  side  of  the  cervix  toward  the  kidney. 
It  is  normally  a  flattened,  cord-like,  soft,  yielding  band.  Patho- 
logical changes  sometimes  may  make  it  easy  to  recognize  as  a  hard, 


80  GENERAL  PRINCIPLES. 

round,  large  resisting  cord.  A  bougie  introduced  through  the  urethra 
into  the  ureter  facilitates  the  palpation.  Tenderness  along  the  line 
of  the  ureter  indicates  inflammation  ;  this  inflammation  of  the  ureter, 
when  unrecognized,  often  leads  to  disappointment  in  the  treatment  of 
cystitis. 

The  interior  of  the  bladder  may  be  palpated  by  the  sound  or  by  the 
finger.  The  sound  enables  one  to  judge  of  the  presence  or  absence  of 
a  stone  or  a  tumor.  Vesical  hemorrhage  following  the  introduction 
of  the  soimd  indicates  the  possible  presence  of  inflammation  or  of  a 
tumor.  Palpation  by  the  finger  through  a  dilated  urethra  is  to  be 
condemned,  for  two  reasons  :  first,  it  gives  no  information  which  can- 
not be  obtained  better  by  means  of  the  cystoscope ;  second,  permanent 
incurable  incontinence  of  urine  from  injury  to  the  urethra  occurs  in 
about  3  per  cent,  of  the  cases.  Digital  exploration,  if  made  at  all, 
should  be  made  through  a  vesicovaginal  fistula  opened  for  the  purpose. 
See  Cystotomy  for  Cystitis. 

The  presence  or  absence  of  cystocele,  urethrocele,  prolapse  of  the 
urethra,  inflammation,  and  new  growths  about  the  meatus  may  be 
recognized  by  direct  visual  examination.  See  Inflammation  of 
Skene's  Glands,  under  Vulvovaginitis. 

3.  Urethroscopy. — The  entire  raucous  membrane  of  the  urethra 
may  be  brought  into  view  by  means  of  a  urethroscope.  There  are 
many  varieties,  most  of  them  of  the  cylindrical  form.  The  urethro- 
scope is  inserted  with  the  obturater  the  whole  length  of  the  urethra 
and  the  mucosa  is  brought  into  view  as  the  tube  is  withdrawn.  The 
cylindrical  cystoscope  of  Kelly  answers  the  purpose,  the  only  objection 
to  it  being  its  excessive  length. 

4.  Cystoscopy  and  Ureteral  Exploration  and  Catheteriza- 
tion.— There  are  two  classes  of  cystoscopes  :  they  are — 

The  cylindrical  cystoscope ; 
The  electrical  cystoscope. 
The  Cylindrical  Cystoscope. — Numerous  instruments  have  been  de- 
vised for  inspection  of  the  interior  of  the  bladder.     It  is  the  great 
merit  of  Howard  Kelly  to  have  popularized  and  perfected  an  effec- 
tive and  satisfactory  means  of  intravesical  inspection.     The  following 
is  a  description  of  the  instruments  and  methods  used  by  Kelly. 
The  essential  features  of  the  method  are  : 

1.  Atmospheric  dilatation  of  the  bladder  induced  by  posture. 

2.  Introduction  of  a  simple  straight  speculum  without  fenestrum. 

3.  Examination  of  the  interior  of  the  bladder  and   urethra  by 

reflected  light. 
The  instruments  required  are  : 

1.  A  good  light  and  a  head-mirror. 

2.  A  urethral  dilator.  Figure  30,  a. 

3.  A  vesical  speculum  with  an  obturator,  Figure  29,  e. 

4.  A  suction  apparatus  to  empty  the  bladder,  Figure  31,  X. 

5.  A  long  mouse-tooth  forceps.  Figure  30,  d. 

6.  A  searcher  for  discovering  the  ureteral  orifice.  Figure  29,  b. 

7.  Ureteral  bougies  and  ureteral  catheters. 

The  speculum  in  most  common   use  has  a  diameter  of  1  cm.     If 


DIAGNOSIS.  81 

urethral  dilatation  to  this  extent  is  painful,  one  may  produce  local 
anaesthesia  by  the  application  of  a  10  per  cent,  solution  of  cocaine  to  be 
applied  within  the  meatus  on  a  uterine  applicator  wound  with  cotton. 
In  cases  requiring  more  dilatation  and  in  very  nervous  cases  general 
anaesthesia,  especially  in  the  first  examination,  may  be  necessary. 

The  numerous  graduated  instruments  formerly  used  to  dilate  the 
urethra  are  unnecessary.  Stretching  of  the  meatus  by  the  conical  dila- 
tor alone  has  been  found  sufficient. 

A  full  set  of  specula  comprises  various  sizes  ranging  in  diameter 
from  5  to  20  mm. — i-  to  f  inch.  The  latter,  according  to  Simon, 
is  the  limit  of  safe  dilatation.  For  some  urethras  it  is  doubtless 
beyond  the  limit,  and  may  so  injure  the  urethra  as  to  destroy  retentive 
power. 

The  position  of  the  patient  is  the  chief  essential.  It  may  be  the 
dorsal  or  the  knee-breast  position. 

For  Examination  in  the  Dorsal  Position  the  hips  of  the  patient  must 
be  elevated  about  twelve  inches  above  the  plane  of  the  table.  Figure 
29.  The  speculum  now  being  introduced  through  the  urethra,  the  air 
rushes  in  and  balloons  the  bladder.  The  residual  urine  must  be  re- 
moved by  means  of  the  suction  apparatus.  Figure  31,  x.  The  entire 
interior  of  the  bladder  may  then  be  examined  by  light  reflected  from 
a  head-mirror.  The  examination  is  made  best  in  a  dark  room  by 
light  from  an  Argand  burner  or  electric  light. 

The  extent  of  surface  seen  at  one  time  will  depend  upon  the  dis- 
tance of  the  eye  from  the  cystoscope,  as  well  as  upon  the  diameter 
of  the  instrument  and  its  nearness  to  the  field  of  vision.  By  sweep- 
ing the  cystoscope  from  side  to  side,  up  and  down  and  around,  all 
parts  may  be  brought  rapidly  and  successively  to  view.  One  may 
observe  and  identify  a  wide  variety  of  pathological  conditions,  such 
as  neoplasms,  inflammation,  ulceration,  scars,  dilated  vessels,  dis- 
coloration, and  foreign  bodies.  The  most  significant  points  of  obser- 
vation are  the  trigone  and  the  openings  of  the  ureters. 

To  expose  the  trigone,  withdraw  the  speculum  until  the  mucous 
membrane  of  the  inner  extremity  of  the  urethra  begins  to  close  over 
it ;  then  advance  it  and  slightly  depress  the  outer  end.  The  mucosa 
at  this  point  is  usually  of  a  dark-pink  color,  in  contrast  to  the  lighter 
glistening  appearance  of  the  surrounding  surfaces. 

To  expose  the  ureters,  let  the  end  of  the  speculum  project  into  the 
bladder  one  centimetre,  with  its  handle  raised.  The  inter-ureteric 
ligament  may  in  some  cases  be  recognized  by  its  slightly  raised  trans- 
verse fold  or  by  its  distinct  diiference  in  color.  A  ureteral  orifice 
should  now  be  seen  by  turning  the  speculum  about  30  degrees  to 
either  side.  By  continuous  watching,  little  jets  of  urine  will  be  seen 
to  spurt  from  the  ureteral  opening  at  intervals  of  about  a  minute.  The 
appearance  about  the  ureteral  opening  is  variable.  In  cases  difficult  to 
catheterize  it  can  only  be  recognized  by  the  periodic  spurts  of  urine  ; 
or  it  may  be  seen  with  great  difficulty  only  as  a  fine  slit  in  the  mucosa ; 
or  the  opening  may  be  in  a  slight  dejiression — a  pit  or  dimple.  In 
some  inflammatory  cases  the  opening  may  be  through  an  eminence  of 
soft  granular  tissue  or  through  the  apparently  everted  ureteral  mucosa. 
6 


82 


GENERAL  PRINCIPLES. 


If  the  ureteral  orifice  is  in  view,  the  ureteral  catheter  on  one  or  both 
sides  may  be  introduced,  and  the  urine  taken  directly  as  it  (lows  from 


Figure  29. 


Cystoscopy  by  Kelly's  method;  patient  in  dorsal  position:  e.  No.  10  cyitoscope  ,  actual  size; 
/,  cystoscope,  without  obturator;  g,  obturator. 

the  kidneys.  The  beginner  ^v\\\  often  have  great  difficulty  in  finding 
the  ureter.  Even  the  experienced  surgeon  often  fails.  The  dif- 
ficulty, however,  always  decreases  with  intelligent  practice. 


DTA  GNOSIS. 


83 


Examination  in  the  Knee-breast  Position. — In  many  cases,  especially 
of  stout  women,  in  which  iho  bhiJder  does  not  readily  balloon  with  air 


FlGUEE  30. 


Cystoscopy  by  Kelly's  method,  with  the  patient  in  the  knee-breast  position:  a,  urethral 
flilator,  underscored  niimerals  indicate  diameters  in  millimetres;  h,  ureteral  searcher ;  e,  ure- 
teral catheter ;  d,  fine  mouse-tooth  forceps  for  use  inside  the  bladder. 

m  the  dorsal  position,  it  will  do  so  in  the  knee-breast  position.  Fig- 
ure 30  shows  this  position  as  modified  by  Kelly,  with  the  bnttocks 
directly  over  the  calves  of  the  legs  or  ankles,  instead  of  vertically  over 


84 


GENERAL  PRINCIPLES. 


the  thighs.     This  modification  yields  better  results,  both   in  difficult 
and  in  simple  cases. 


Figure  31. 


Cystoscopy  and  catheterizing  the  ureters,  Kelly  method  :  X,  evacuator  used  for  withdraw- 
ing residual  urine;  Y,  hand  holding  cystoscope  ,  as  if  for  introduction;  Z,  cotton  wound  on 
stick  for  removing  fluid  from  bladder. 


The  examination  is  conducted  on  the  same  principles  as  in  the 
dorsal  position.  Examination  in  this  position  requires  the  end  of  the 
cystoscope  to  be  cut  off  obliquely,  instead  of  transversely. 


DIAGNOSIS. 


85 


The  Electrical  Cystoscope. — This  instrument  was  invented  by  Leiter, 
of  Vienna,  and  later  improved  by  (Jasper.  Both  the  Leiter  and  Cas- 
per instruments  carried  the  electric  light  ray  into  the  bladder  by  means 
of  refracting  prisms  at  the  external  end  of  the  tube.  In  1876  Nitze 
placed  the  vacuum  light  at  the  inner  extremity  of  the  tube  in  such 
a  manner  as  to  give  direct  illumination  and  to  transmit  to  the  eye 
through  a  series  of  lenses  an  exact  picture  of  the  bladder  mucosa  mag- 
nified. In  all  these  instruments  the  electric  current  is  furnished  by  a 
battery  from  which  insulated  conductors  pass  through  the  tul)e  to  and 
from  the  lamp.     This  instrument  is  used  with  the  bladder  filled  with 

F^GUKE   32. 


The  syringe  is  represented  here  in  hard  rnbber.  An  instrument  with  metallic  barrel  and 
metallic  piston  is  preferable  because  it  permits  frequent  disinfection  by  boiling,  and  because 
boiling  injures  the  rubber  instrument.  A,  tilling  of  bladder  with  water," preparatory  to  cystos- 
copy, by  means  of  syringe,  to  which  glass  catheter  is  attached  by  rubber  tube;  B,  coniplete 
syringe  ;  G.c,  glass  catheter :  R.t.,  rubber  tube. 

water  and  with  the  patient  in  the  ordinary  dorsal  position.     Four  con- 
ditions are  essential  to  the  use  of  the  electrical  cystoscope  : 

1.  Permeability  of  the  urethra — 5  mm. — sufficient  to  permit  the 
ready  passage  of  the  instrument. 

2.  The  capacity  of  the  bladder  must  be  sufficient  to  hold  not  less 
than  100  c.c.  of  injected  fluid. 

3.  The  sphincter  vesicoe  must  have  the  power  to  retain  the  injected 
fluid. 

4.  The  injected  fluid  must  remain  transparent,  and  not  become 
clouded  by  admixture  of  blood  or  mucus. 


86 


GENERAL  PRINCIPLES. 


Advocates  of  this  method  claim  superiority  over  the  Kelly  method 
for  the  following  reasons  : 

1.  General  or  local  anaesthesia  is  less  often  necessary. 

2.  The  more  convenient  lithotomy  position  is  used  instead  of  the 
knee-])reast  or  Trendelenburg  position. 

3.  The  bladder  is  distended  more  satisfactorily  by  water  than  by  air. 

4.  The  urethra  is  dilated  less  widely. 

5.  The  examination  requires  less  time  and  less  skill,  and  requires 
no  assistant. 

Comparison  of  Cystoscopes. — It  is  evident  that  the  Nitze  cystoscope 
and  the  modifications  of  it,  such  as  Casper's,  are    superior    to   the 


Figure  33, 


Catheterization  of  left  ureter  by  Casper  cystoscope.  Upper  right-hand  figure  shows  terminal 
part  of  Casper  cystoscope,  with  lamp  and  catheter,  slightly  reduced  size.  Lower  left-hand 
figure  shows  Nitze  cystoscope,  about  one-third  natural  size. 

Kelly  instrument  when  the  sphincter  vesicse  will  not  retain  the 
injected  fluid,  when  the  injected  fluid  becomes  turbid  and  bloody, 
and  when  the  bladder  is  so  contracted  that  it  fails  to  distend  sufficiently. 
Cystoscopy  and  ureteral  exploration  in  women,  owing  to  the  shortness 
and  dilatability  of  the  urethra,  may  be  accomplished  satisfactorily  by 
means  of  the  simple  Kelly  cystoscope  already  described.  In  examin- 
ations of  the  male  urethra  the  prismatic  electroscope,  on  account  of 
its  magnifying  power  and  the  greater  distance  of  the  field  of  inspec- 
tion from  the  eye,  is  indispensable. 

The  Kelly  instrument  has  the  advantage  over  the  electrical  cysto- 
scope of  not  exposing  the  bladder  to  burns ;  and  of  giving  a  more 
accessible  field  for  topical  applications. 

Value    of    Cystoscopy    and    Ureteral    Catheterization. — By    means 


DIAGNOSIS. 


87 


of    the    cystoscope    the    entire    interior    of    the    bladder    may    be 
brought  into  view;    foreign  bodies,  tumors,  and  other  pathological 


Figure  34. 


Catheterization  of  both  ureters  by  (  asper  cystoscope.  Ri^ht  ureter  has  been  catheterized 
and  cystoscope  withdrawn,  leaving  catheter  in  ureter.  Cystoscope  again  introduced,  and  left 
ureter  being  catheterized ;  R-C,  catheter  in  right  ureter;  L-C,  catheter  being  passed  into  left 
ureter ;  A  and  B,  forceps  and  snare  for  intravesical  operations ;  a,  rheophores. 

changes  may  l)e  recognized.  The  instrument  often  has  revealed 
the  presence  of  stones,  tumors,  and  ulcers  which  had  escaped 
detection  by  the  sound.     Numerous  cases  in  which  cystitis  is  of  only 


88  GENERAL  PRINCIPLES. 

secondary  importance  to  other  associated  lesions,  such,  for  example, 
as  tumors,  tuberculous  ulcers,  hemorrhoids  of  the  bladder,  are  now 
daily  observed  by  the  cystoscope.  Cystoscopy  is  of  great  value  in 
preventing  blind  and  meddlesome  treatment  for  a  class  of  cases  which 
present  the  subjective  symptoms  of  cystitis,  but  in  which  inspection 
fails  to  show  any  lesion  whatever  of  the  bladder  mucosa.  The  value 
of  the  instrument  is  incalculable  when  only  limited  areas  are  diseased, 
as,  for  example,  in  the  mild  inflammations  of  the  trigone  and  in  fis- 
sure at  the  neck  of  the  bladder.  Under  such  conditions  the  operator, 
instead  of  treating  the  entire  vesical  mucosa  by  means  of  injections 
more  or  less  strong,  may  direct  to  the  diseased  part  only  any  applica- 
tion which  may  be  indicated. 

FIC4UEE   35. 


Cystoscopy  of  phantom  bladder  through  the  Nitze  cystoscope. 


By  ureteral  catheterization  we  are  enabled  to  separate  the  urine  of 
the  one  kidney  from  that  of  the  other,  and  temporarily,  as  it  were,  to 
eliminate  the  bladder  from  the  urinary  tract.  In  case  of  a  diseased 
kidney  marked  for  removal  one  may  demonstrate  the  presen(;e  or 
absence  or  ascertain  the  condition  of  the  other  kidney,  and  thereby 
avoid  the  post-mortem  embarrassment  of  finding  it  either  absent 
or  useless  from  disease. 

It  is  necessary  to  a  correct  diagnosis  of  cystitis,  for  example,  that 
we  know  what  abnormal  constituents  in  the  urine  have  their  origin 
within  the  bladder  itself.  Normal  urine  suffers  no  change  in  a  normal 
bladder  free  from  microbes ;  hence  a  comparison  of  analyses  of  urine 
taken  from  the  bladder,  with  urine  taken  directly  from  each  kidney, 
may  at  once  indicate  the  exact  location  of  the  disease.     There  mav 


DIAGNOSIS. 


89 


be  present  the  subjective  symptoms  of  cystitis — that  is,  pyuria,  pain- 
ful and  frequent  urination,  and  ammoniacal  urine — and  yet  the  bladder 
may  be  free  from  disease. 

The  points  to  be  observed  in  urine  thus  obtained  are  the  reaction 
and  the  presence  or  absence  of  pathological  products,  such  as  pus, 
blood,  epithelial  cells,  bacteria,  and  crystals.  The  reaction  of  the 
urine  should  be  taken  at  once,  as  secondary  changes  sometimes  occur 
quite  rapidly.  If  urine  taken  directly  from  the  kidneys  possess  a 
normal  degree  of  acidity,  while  that  from  the  bladder  be  alkaline, 
it  is  evident  that  the  pathological  process  producing  the  alkalinity 
must    be    within  the  bladder.     If  urine  from  the  kidneys  be  free 

Figure  36. 


Urine  being  taken  through  each  ureter  separately  by  means  of  the  Harris  segregator :  C.  cath- 
eters ;  D,  watershed  lever  attached  to  catheters,  and  in  use  ;  bb  and  bb,  catheters  closed  and  par- 
tially open  ;  D.  watershed  lever  detached  from  catheters  :  R,  bottle  connected  by  rubber  tube  to 
right  catheter;  L,  bottle  connected  by  rubber  tube  to  left  catheter.  These  bottles  receive  the 
urine  from  the  right  and  left  ureters  respectively  :  E,  rubber  bulb  attached  by  rubber  tubes  to 
bottles.  This  bulb  is  used  to  exhaust  the  air  partially  from  the  bottles,  so  that  the  urine  may 
flow  more  readily :  aa  ana  aa,  ends  of  catheters  where  bottles  are  attached. 


from  pathological  products,  while  that  from  the  bladder  contains  pus, 
epithelium,  or  bacteria,  the  involvement  of  the  bladder  is  unques- 
tionable. 

5.  Segregation. — Another  instrument  of  importance  is  the  segre- 
gator  of  Harris ;  it  collects  the  urine  directly  and  separately  as  it 
passes  from  each  ureter  into  the  bladder.  The  instrument  has  two 
advantages  over  the  ureteral  catheter  :  first,  unlike  that  in.'^trument, 
it  is  available  for  the  non-expert ;  second,  it  does  not  invade  and 
therefore  cannot  infect  the  ureters.  The  instrument  consists  of  two 
catheters,  their  straight  portions  being  enclosed  in  a  flattened  tube, 
and  each  being  separate  and  movable  on  its  longitudinal  axis.  Figure 
36  shows  the  tube  graduated  to  19  centimetres  and  enclosing  the  two 


90  GENERAL  PRINCIPLES. 

catheters.  Their  vesical  ends  protrude  from  the  tube  to  the  right  and 
their  outer  ends  to  the  left.  The  mechanism  is  such  that,  the  instru- 
ment having  been  introduced  into  the  bladder,  the  two  catheters  may 
be  rotated  upon  their  long  axis  so  that  their  curved  bladder-ends  will 
lie  as  indicated  in  Figure  36,  C,  one  on  one  side  and  the  other  on  the 
other  side  of  the  trigone.  A  metallic  lever,  D,  is  introduced  into  the 
vagina  of  the  female,  or  the  rectum  in  the  male,  and  attached  to  the 
shaft  of  the  instrument.  This  lever  is  represented  detached  in  the 
lower  part  of  the  Figure.  It  is  attachable  to  the  catheter  tube  by  means 
of  a  forked  metallic  appliance,  and  held  up  by  a  spiral  spring ;  the 
function  of  it  is  to  elevate  that  portion  of  the  bladder  which  lies 
between  the  two  separated  ends  of  the  rotated  catheters  and  thereby 
to  form  a  watershed.  The  urine  as  it  drops  on  either  side  from  each 
ureteral  orifice  is  now  separated  and  flows  out  through  the  catheter  on 
the  corresponding  side.  Each  catheter  is  continued  by  a  rubber  tube 
to  a  bottle  for  the  reception  of  urine.  Tlie  bottles  are  provided  with 
a  rubber  suction  bulb  which  may  serve  to  create  a  partial  vacuum  and 
thereby  to  attract  the  urine.  For  obvious  reasons  the  bladder  should 
be  washed  out  before  the  segregator  is  introduced.  Before  using  the 
segregator  one  should  study  carefully  the  directions  of  the  inventor, 
which  accompany  the  instrument.^ 

Exploratory  Incision. 

When  other  means  of  diagnosis  have  failed,  and  it  is  necessary  to 
examine  the  pelvic  or  abdominal  organs  directly  by  touch  or  by  sight, 
the  surgeon  will  for  that  purpose  open  the  peritoneum  by  exploratory 
incision.  The  incision  is  made  either  through  the  vagina — vaginal 
section,  or  through  the  abdomen^abdorainal  section.  The  incision 
having  been  made,  the  finger  is  introduced  and  the  diagnosis  made 
by  direct  touch.  The  section  may  be  enlarged,  if  necessary,  so  as  to 
bring  the  pelvic  and  abdominal  contents  into  view.  Simple  touch, 
however,  through  the  incision  only  large  enough  to  admit  the  finger, 
is  always  safer  and  usually  gives  more  information  than  visual  exam- 
ination. All  vaginal  and  abdominal  incisions  should  be  first  explora- 
tory. 

1  Harris,  Transactions  of  the  Chicago  Gynecological  Society,  November,  1898;  and  Medicine, 
April,  1898. 


CHAPTER    IV. 

LOCAL  TREATMENT. 

The  principal  procedures  in  local  treatment  are  these : 

1.  The  hot-water  vaginal  douche. 

2.  Tamponade. 

3.  Topical  applications. 


1.  THE  HOT  VAGINAL  DOUCHE. 


The  choice  of  the  syringe,  the  frequency  of  the  douche,  the  time 
and  length  of  each  application,  the  temperature  of  the  water,  the 
proper  use  of  the  bed-])an,  the  position  of  the  patient,  and  persistence 
in  the  treatment,  are  all  essential  to  good  results. 


Figure  37. 


UTERINE      syringe;      CAPACITY     60     MIMIMS 


Some  of  the  instruments  commonly  used  in  local  treatment.    About  one-third  natural  size. 

The  small  fountain  syringe  in  general  use  requires  refilling  several 
times  during  the  application  of  the  douche.  A  large  syringe-bag  or 
receptacle  of  some  kind  to  supply  the  w'ater  is  therefore  desirable. 
The  common  bed-pan  is  objectionable  because  it  must  frequently  be 
emptied.     To  overcome  this  difficulty,  F.  H.  Lord  attaches  a  rubber 

91 


92 


GENERAL  PRINCIPLES. 


tube  to  the  bed-pan  through  which  the  water  is  drained  continuijusly 
to  a  bucket  below  tlie  couch. 

A  satisfactory  substitute  for  the  bed-pan  may  be  made  as  follows  : 
at  the  side  of  an  ordinary  bed  place  two  chairs  with  space  enough 
between  them  to  admit  the  lower  bucket ;  spread  a  rubber  sheet  over 
the  side  of  the  bed  so  that  one  end  of  the  sheet  may  fall  into  the  bucket 
below  in  the  form  of  a  trough.  The  douche  may  then  be  given  Avith 
the  patient  lying  across  the  bed,  the  hips  resting  over  the  edge  of  the 

Figure  38. 


Rubber  sheet  substituted  for  the  bed-pan. 


bed  and  one  foot  on  each  chair.     The  water  will  find  its   way  along 
the  rubber  trough  into  the  bucket  below. 

The  following  is  designed  to  impress  the  importance  of  strict  ob- 
servance of  detail  in  the  application  of  the  douche.  In  no  other 
manner  will  its  good  eifects  be  realized  : 


Ordinary  method  of  application. 

I. 

The  douche  is  applied  with  the  patient  in 
the  sitting  posture,  so  that  the  injected  water 
cannot  fill  the  vagina  and  bathe  the  cervix 
uteri,  but  instead  returns  along  the  tube  ot 
the  syringe  as  it  flows  in. 


The  patient  is  not  impressed  with  the  im- 
portance of  regularity  in  its  administration. 


Proper  method  of  application. 

I. 

The  douche  should  invariably  be  given  with 
the  patient  lying  on  the  back,  with  the 
shoulders  low",  the  knees  drawn  up,  the  hips 
elevated  so  that  the  outlet  of  the  vagina  may 
be  above  every  other  pnrt  of  it.  Then  the 
vagina  will  be  "kept  continually  overflowing 
while  the  douche  is  being  given. 

IT. 

It  should  be  given  at  least  twice  every  day, 
morning  and  evening,  and  generally  the 
length  of  each  application  should  be  not  less 
than  twenty  minutes. 


LOCAL   TREATMENT.  93 

Ordinary  method  of  application.  Proper  method  of  application. 

HI.  III. 

The    temperature    is    not  specified,  or    if  The  temperature  should  be  as  high  as  the 

specified,  is  not  heeded  by  the  patient.  patient  can  endure  witliout  distress.    It  may 

be  increased  from  day  to  day,  from  100°  or 
105°  to  115°  or  120°  Fahr. 


IV.  IV. 

Its  use,  in  the  majorit; 
continued  at  least  for  mi 
is  of  prime  importance. 


The  patient  abandons  its  use  after  a  short  Its  use,  in  the  majority  of  cases,  should  be 

time.  continued  at  least  for  months.    Perseverance 


The  pressure  of  the  water  should  be  low  and  the  douche-point  short, 
for  cases  have  been  recorded  in  which  the  water  was  forced  with 
unfortunate  results  through  the  Fallopian  tubes. 

Modes  of  Action. — The  douche  acts  in  a  twofold  way  : 

1.  As  a^vascular  stimulant. 

2.  As  a  cleansing  agent. 

1.  Vascular  Stimulant. — Emmet,  the  strongest  advocate  of  the 
douche,  attributes  its  good  effects  to  the  stimulating  influence  of  the 
hot  water  on  the  blood-vessels.  The  dilated  congested  vessels  are,  he 
says,  made  to  contract,  and  in  this  way  congestion  is  lessened,  circula- 
tion quickened,  absorption  of  morbid  products  hastened,  and  local 
nutrition  improved. 

2.  Cleansing  Agent. — The  vagina  in  pelvic  inflammation  is  a  pas- 
sage-way, and  to  some  extent  a  receptacle,  for  pathological  secretions. 
These  secretions  flow  into  it  from  the  uterus,  the  Fallopian  tubes, 
pelvic  abscesses,  and  from  the  vaginal  mucous  membrane  itself.  Un- 
less kept  clean,  the  vagina  may  become  an  incubator  and  a  distribut- 
ing-point for  bacteria.  The  value  of  the  douche,  therefore,  as  a  means 
of  asepsis  is  self-evident.  When  local  disinfection  is  required,  the 
hot-water  douche  may  have  in  solution  some  antiseptic  substance,  such 
as  lysol,  carbolic  acid,  corrosive  sublimate,  boric  acid,  salicylic  acid, 
peroxide  of  hydrogen,  or  formalin. 

The  Indications  for  the  douche,  as  suggested  in  the  foregoing  ])ara- 
graphs,  are  chiefly  in  the  treatment  of  chronic  pelvic  inflammations. 
The  power  of  heat  to  stimulate  and  contract  blood-vessels  makes  the 
douche  also  useful  in  the  treatment  of  uterine  hemorrhage.  The  pre- 
vailing disposition  to  extend  the  use  of  it  to  the  routine  treatment  of 
all  pelvic  disorders  should  be  discouraged. 

Contraindications  and  Dangers.— The  douche  should  not  ordi- 
narily be  given  during  menstruation  for  fear  of  exciting  pelvic  con- 
gestion, nor  during  pregnancv  for  fear  of  causing  uterine  contrac- 
tions. In  the  presence  of  a  bleeding  cancer  or  sarcoma  of  the  cervix 
caution  is  required  to  avoid  hemorrhage.  In  some  cases  of  patulous 
Fallopian  tubes  the  douche  fluid  may  be  forced  into  the  uterus,  through 
the  tubes  and  into  the  peritoneal  cavity,  with  most  serious  results. 

There  are  constantly  present  in  the  normal  vagina  numbers  of 
lactic-acid-producing  bacteria  whose  function  is  to  render  the  vagi- 
nal secretions  acid,  and  tlierefore  to  make  it  an  unfit  culture-ground 
for  about  90  per  cent,  of  all  pathogenic  bacteria.  The  washing  out  of 
these  normal  germs  and  the  acid  secretion  may  make  the  vagina  pos- 
sibly a  less  difficult  barrier  for  disease-germs  to  pass,  and  therefore 


94 


GENERAL  PRINCIPLES. 


may  open  the  way  for  infection  in  the  higher  zones  of  the  pelvis.  ^  The 
routine  use  of  the  douche  in  the  normal  vagina  except  for  ordinary 
purposes  of  bathing  is  for  this  reason  of  questionable  propriety. 


2.  TAMPONADE. 

The  principal  indications  for  tamponade  are : 

1.  Inflammation. 

2.  Hemorrhage. 

1.  Inflammation. — Tamponade  in  the  treatment  of  inflammation  is 
designed,  according  to  the  indication  and  manner  of  application,  to 
fulfil  one  or  more  of  three  purposes.  It  may  be  used  :  A,  as  a  means 
of  pressure  ;  B,  as  a  vehicle  for  the  application  of  medicinal  substances; 
C,  for  drainage. 

FiGtIKE   39. 


TAMPON;      THREAD    LYINQ     ACROSS 


SAME  WITH'ENDS  FOLDLD; 
THREAD  PART! ALLY  TIED. 


SA 
TA 


READ  TIED; 
hIPLETE. 


The  making  of  a  vaginal  tampon  of  lamb's  wool.    One-half  natural  size. 

A.  The  Pressure-effect  of  the  tampon  is  chiefly  useful  in  the  treat- 
ment of  displacements,  especially  displacements  due  to  inflammatory 
causes.  The  subject  will  be  discussed  further  under  the  head  of 
Pelvic  Inflammations  and  Displacements. 

B.  As  a  Vehicle  for  the  Introduction  of  Medicaments  the  vaginal 
tampon  has  become  a  routine  factor  in  gynecology.  It  is  used  most 
frequently  as  a  carrier  of  glycerin.  The  efl'ect  of  the  glycerin  is  to 
cause  a  watery  discharge  from  the  genital  tract,  and  thereby  to  deplete 
the  vessels  and  overcome  congestion.     Good  results  often  have  fol- 


LOCAL   TREATMENT. 


95 


lowed  this  treatment.  How  far  they  should  be  attributed  to  the 
tampon,  and  how  far  to  the  curative  forces  of  nature,  or  to  associated 
systemic  treatment,  it  is  often  difficult  to  say.  If  the  tampon  is  left 
in  for  more  than  twenty-four  hours,  it  becomes  offensive,  and  may 
become  a  hotbed  of  infection ;  hence,  if  used  at  all,  it  should  be 


Figure  40. 


VAGINAL    PACKING   WITH 
LONG    WOOL   TAMPOK. 


Intra-uterine  application  and  vaginal  tam])onade. 


removed  at  the  end  of  twenty-four  liours.     The  therapeutic  value  of 
the  tampon  has  been  much  overestimated. 

C.  Drainage  of  the  Endometrium  for  endometritis,  by  means  of  the 
intra-uterine  tampon  of  aseptic  or  antiseptic  gauze,  has  been  a  favorite 
means  of  treatment.     See  chapter  on  Treatment  of  Endometritis. 


96  GENERAL  PRINCIPLES. 

2.  Hemorrhag"e. — Hemorrhage  from  the  vagina  often  may  be  con- 
trolled by  means  of  a  tight  vaginal  tampon.  It  is,  however,  better  to 
find  the  bleeding-point  and  secure  it  by  more  definite  surgical  means. 
Uterine  hemorrhage,  whether  from  endometritis,  uterine  tumors,  or 
abortion,  may  demand  immediate  control.  The  vaginal  tampon  is 
nsed  most  commonly  for  this  purpose.  It  is,  however,  a  cumbersome 
measure  in  severe  cases  and  often  fails.  Great  distention  of  the  vagina 
by  a  large  tampon  interferes  with  the  function  of  the  bladder  and  rec- 
tum, and  is  a  mechanical  cause  of  discomfort.  The  intra-uterine  tam- 
ponade is  the  most  practical  and  the  most  eifective  treatment  tor 
uterine  hemorrhage.  It  should  be  in  the  form  of  a  continuous  strip 
of  aseptic  or  antiseptic  gauze  two  inches  or  more  wide.  The 
cervix  having  been  exposed  by  a  Sims  speculum  and  steadied  by  a 
vulsellum  forceps,  the  strip  is  introduced  by  means  of  a  slender  dress- 
ing-forceps, sound,  or  similar  instrument.  The  secretions  absorbed 
by  the  tampon  decompose  rapidly,  and  become  a  prolific  source  of  in- 
fection ;  hence  the  gauze  should  be  renewed  daily  or  at  most  every 
two  days. 

Material  of  the  Tampon. — If  elastic  pressure  is  required,  fine  lamb's 
wool  is  superior  to  absorbent  cotton.  For  other  purposes  the  continu- 
ous strip  of  aseptic  gauze  is  preferable  to  either. 

3.  TOPICAL  APPLICATIONS. 

Applications  to  the  Endometrium. — Intra-uterine  medication 
commonly  results  in  failure  and  disappointment,  for  two  principal 
reasons  :  first,  it  often  is  used  in  unsuitable  cases ;  second,  even  though 
the  cases  be  suitable,  it  often  is  used  improperly. 

Efficient  intra-uterine  medication  requires  that  the  medicinal  sub- 
stance be  brought  in  contact  with  the  uterine  mucosa.  Ordiuarily 
the  medicament  is  carried  into  the  endometrium  when  that  cavity  is 
full  of  uterine  secretions.  These  secretions  form  a  thick  protective 
coating  over  the  mucosa.  The  application  mixes  Avith  and  may  ex- 
haust its  virtue  in  chemical  combination  with  the  secretions,  but  does 
not  reach  the  diseased  mucous  membrane.  It  frequently  occurs  that 
the  applicator  at  various  points  inflicts  slight  wounds  upon  the  endome- 
trium, and  thereby  opens  the  door  to  septic  invasion.  Pelvic  infection 
may  be  the  result.  The  treatment,  therefore,  unless  carefully  applied, 
may  be  dangerous. 

The  prerequisites  to  safe  and  efficient  intra-uterine  applications  are  : 
first,  a  clear  indication  and  definite  appreciation  of  what  the  applica- 
tion is  to  accomplish — that  is,  the  case  must  be  selected  properly  ;  sec- 
ond, preparatory  disinfection  of  the  vulvovaginal  surfaces  and  dilata- 
tion and  cleansing  of  the  endometriimi  ;  the  disinfection  is  specially 
essential  as  a  precaution  against  infection. 

The  Proper  Selection  of  Cases  will  exclude,  at  least,  three  large 
classes  of  cases : 

A.  Those  cases  in  which  the  increased  uterine  discharge  is  due 
simply  to  an  eifort  on  the  part  of  the  organ  to  relieve  itself  of  conges- 
tion by  increased  secretion — that  is,  cases  in  which  the  discharge  is  not 
due  to  infection.     The  congestion  of  the  mucosa  under  such  conditions  is 


LOCAL    TREATMENT. 


97 


very  apt  to  be  associated  with  some  systemic  disorder,  such  as  chol- 
aemia,  malaria,  diabetes,  gout,  anaemia,  or  heart  lesions.  These  cases 
should  be  treated  by  general  rather  than  local  remedies,  and  should 
be  referred  to  a  physician.  The  disappearance  of  such  a  discharge 
during  local  treatment  should  be  attributed  not  to  the  meddlesome 
applications,  but  to  the  associated  systemic  treatment  or  to  the  cura- 
tive force  of  nature. 

Figure  41. 


UTERUS     DRAWN    DOWN 
WITH    TENACULUM. 


EMMETS    DRESSINQ    F  O  RCEPS  WOUND   WITH  COTTON 
FOR      INTRAUTERINE    APPLICATION.  p 


Intra-uterine  injection,  and  Emmet's  dressing-forceps  wound  with  cotton  for  intra- 
uterine application. 

B.  Those  cases  in  which  the  parametria,  Fallopian  tubes,  and  other 
circumuterine  structures  are  infected,  or  in  which  there  is  a  uterine 
or  extra-uterine  tumor,  or  some  other  anomaly  which  would  render 
topical  applications  useless  or  dangerous.  This  class  of  cases  should 
be  referred  to  the  surgeon. 

C.  Those  cases  in  which  the  uterine  discharge  is  due  to  some  non- 
infectious local  irritant  of  non-bacterial  origin,  such,  for  example,  as 
temporary  uterine  displacement  from  an  overcrowded  bowel  or  an 
overdistended  bladder.  When  the  local  irritation  is  removed,  the 
disorder  usually  disappears. 

For  selected  cases  in  which  the  uterine  mucosa  is  the  subject  of 
imcomplicated  bacterial  infection,  or  in  which  the  complications  are 


98  GENERAL   PRINCIPLES. 

not  such  as  to  contraindicate  intra-uterine  medication,  it  may  be  wise 
to  introduce  medicinal  substances  to  the  endometrium  ;  the  steps  of 
procedure  will  have  to  be  as  follows  : 

1.  The  preparatory  dilatation  (unless  the  uterine  canal  is  already 
quite  open)  and  cleansing  by  irrigation  having  been  made,  expose  the 
cervix  by  means  of  a  speculum,  preferably  Sims'. 

2.  Seize  the  cervix  by  means  of  a  small  tenaculum,  or  tenaculum- 
forceps,  in  the  left  hand,"^  and  hold  the  cervix  steady. 

3.  With  the  right  hand  pass  the  applicator,  wound  with  cotton 
which  has  been  saturated  with  the  required  medicament,  into  the 
uterine  canal  ;  or  if  it  be  desired  to  use  intra-uterine  injections,  the 
fluid  to  be  injected  by  means  of  a  suitable  intra-uterine  syringe. 

Many  patients  will  not  tolerate  the  necessary  dilatation  without 
ansesthesia;  hence,  intra-uterine  medication  as  an  office  procedure 
must  be  restricted.  Within  the  limitations  above  outlined,  it  becomes 
in  many  cases  a  surgical  measure,  and  as  such  is  no  longer  a  potent 
cause  of  pelvic  infection.  The  general  subject  of  uterine  applications  is 
set  forth  more  fully  in  the  chapter  on  the  Treatment  of  Endf>metritis. 
It  follows  from  the  above  that  a  very  large  proportion  of  the 
women  who  formerly  were  made  the  subject  of  extensive  intra-uterine 
treatment  should  be  treated  rather  by  medical  or  surgical  means,  or  by 
both  combined.  jNIany  cases  of  excessive  uterine  secretion  which  do 
not  present  well-defined  indications  for  surgical  treatment  should  be 
relegated  to  the  fiald  of  internal  medicine.  The  legitimate  field  for 
routine  topical  applications  to  the  uterus  is  limited.  Some  gynecol- 
ogists restrict  intra-uterine  medication  almost  entirely  to  supplemental 
treatment  after  curettage,  wlien  a  limited  number  of  disinfecting  irri- 
gations or  applications  may  be  useful. 

The  use  of  bougies  containing  various  medicaments,  the  introduc- 
tion of  intra-uterine  suppositories,  the  injection  of  various  fluids  into 
the  uterus,  the  packing  of  the  endometrium  w^th  gauze,  and  other 
similar  procedures,  will,  according  to  their  value,  be  presented,  or 
omitted,  under  the  treatment  of  special  disorders. 

Biers'  Cupping  Treatment. — Biers  and  others  practice  a  method 
of  dry  cupping  the  cervix  uteri  by  means  of  a  suction  pump  in  order 
to  stimulate  the  circulation  of  the  organ  ;  it  is  called  the  congestive 
treatment  and  is  said  to  modify  the  nutrition  of  the  past  favorably  by 
modifying  the  circulation.  The  idea  is  rational,  inasmuch  as  it  tends 
to  correct  those  morbid  conditions  which  depend  upon  faulty  circula- 
tion.    Massage  of  other  parts  is  given  on  the  same  principles. 

Applications  to  the  Vulva  or  Vagina,  including  the  vaginal 
portion  of  the  uterus,  are  indicated  for  the  cure  or  palliation  of  the 
various  inflammatory  aifections  of  those  organs.  Ointments,  lotions, 
douches,  and  strong  caustics  may  be  applied  precisely  as  they  would 
under  similar  conditions  to  other  parts.  See  Treatment  of  Vulvo- 
vaginitis, Chapter  XL 

Direct  treatment  to  the  urethra,  bladder,  and  ureters  will  be  dis- 
cussed in  Chapter  XXIV.,  on  Inflammation  of  the  Urinary  Organs. 

Other  forms  of  local  treatment,  such  as  scarification,  leeching,  and 
electrotherapeutics,  are  of  little  value,  and  in  the  indiscriminate  hand 
are  of  much  harm. 


CHAPTER  V. 

MINOR  OPERATIONS. 

Minor  surgery  involves  a  consideration  of  the  preparatory  treat- 
ment, the  operating-table,  anaesthesia,  instruments,  appliances,  sutures, 
ligatures,  dressings,  the  time  and  place  of  operation,  assistants,  opera- 
tive technique,  and  after-treatment. 

PREPARATORY  TREATMENT. 

The  preparation  for  an  operation,  largely  a  matter  of  antiseptics 
and  asepsis,  is  set  forth  in  Chapter  II. 

Faulty  nutrition  from  any  cause,  such  as  syphilis,  gout,  rheuma- 
tism, nephritis,  diabetes,  or  purpura,  may  interfere  with  the  success 
of  an  operation,  and  may  therefore  call  for  systemic  and  hygienic  treat- 
ment. 

OPERATING-TABLES . 

For  vaginal  operations  the  table  should  be  approximately  forty- 
eight  inches  long,  twenty-four  inches  wide,  and  twenty-seven  inches 
high.  Operations  in  private  houses  are  performed  usually  on  the 
common  kitchen  table  or  laundry  table,  or  upon  the  narrow  dining- 
table.  The  length  of  the  table  should  not  be  greater  than  that  given 
above,  for  when  the  thighs  are  flexed  and  the  patient  drawn  toward 
the  operator  the  head  should  not  be  too  far  from  the  ansesthetizer,  who 
stands  at  the  end  of  the  table  opposite  the  operator.  While  the  patient 
is  being  anaesthetized  the  feet  and  legs  may  rest  temporarily  on  a  chair 
or  small  stand  at  the  foot  of  the  table. 

Clover's  Crutch  is  one  of  the  best  of  numerous  devices  to  hold 
the  thighs  flexed  and  the  legs  in  position  during  those  vaginal  opera- 
tions which  are  done  with  the  patient  in  the  dorsal  position.  Such  an 
apparatus  is  convenient,  but  unnecessary,  for  the  knees  may  be  held 
by  two  assistants,  one  on  each  side. 

Acute  synovitis  of  the  knee-joint  followed  by  anchylosis  has  occa- 
sionallv  been  observed  to  follow  vaginal  operations.  This  was  un- 
explained until  E.  H.  Webster,  of  Evanston,  Illinois,  suggested  that 
an  assistant,  while  holding  the  thighs  in  this  flexed  position,  might 
carelessly  throw  his  weight  upon  the  leg,  or  lean  heavily  upon  it, 
and  thereby  flex  the  joint  to  a  dangerous  degree. 

All  gynecological"  tables,  whether  used  for  examination  or  opera- 
tion, should  be  made  as  suggested  in  Chapter  TIL,  with  an  inclination 
of  three  or  four  inches,  the" foot  of  the  table  being  to  that  extent  above 
the  level  of  the  head  of  it. 

The  accessories  to  the  operating-table  include  knee-rests,  rubber 
sheets,  and  smaller  tables  for  instruments,  dressings,  and  ligatures. 

99 


100  aSNERAL  PRINCIPLES. 


ANESTHESIA. 


The  choice  and  mode  of  ad  ministration  of  ansesthetics  in  gynecology 
follow  unmodified  the  general  principles  of  surgery. 

Ether  and  Chloroform. — In  the  absence  of  heart  or  kidney  lesions 
the  operator,  according  to  his  preference,  is  justified  in  the  choice  of 
ether  or  chloroform.  Ether  is  preferred  generally  in  cases  of  heart 
disease,  and  chloroform  in  cases  of  kidney  disease. 

Local  Anaesthesia  by  Cocaine. — A  solution  of  cocaine  injected  hy- 
podermically  will  produce  local  anaesthesia  in  the  infiltrated  tissues  for  a 
distance  of  about  one-half  inch  from  the  needle  puncture.  The  1  per 
cent,  solution  commonly  is  used  ;  a  sufficient  quantity  of  this  solution 
to  produce  satisfactory  an£esthesia — one  to  two  grains — has  given  rise 
repeatedly  to  alarming  depression  in  the  circulation  and  respiration — 
so  alarming  as  to  call  for  the  strenuous  use  of  whiskey,  strychnine, 
and  nitroglycerin.  The  cocaine  solutions  of  Schleich  are  designed 
to  produce  local  anaesthesia  with  less  cocaine,  and  thus  to  minimize 
the  danger  ;  they  are  made  in  three  strengths  as  follows.  The  basis  of 
the  solution  is  : 

Distilled  water,  1000  parts  ; 
Sodium  chloride,  2  parts  ; 
Morphine  hydrochlorate,  J  part. 
To  the  above  solution  is  added  cocaine  hydrochlorate  : 
Yo-Q-  of  1  per  cent,  for  the  weaker  solution  ; 
Y^Q  of  1  per  cent,  for  the  medium  solution ; 
|-  of  1  per  cent,  for  the  stronger  solution. 
The  medium   solution  is  for  ordinary  use ;  the  weaker  solution  is 
for  use  where  very  large  areas  have  to  be  anaesthetized  for  extensive 
incisions ;  the  stronger  solution  is  for  use  in  very  sensitive  inflamed 
parts. 

After  the  solution  has  been  injected  several  minutes  are  required 
for  surgical  anaesthesia.  The  experiments  of  Schleich  show  that  the 
salt  water  lessens  the  pain  of  infiltration,  and  that  even  the  minute 
dose  of  morphine  prolongs  the  anaesthesia. 

Large  quantities  of  the  solution   may   be  injected  and  extensive 
operations  be  performed  under  this  method  of  anaesthesia. 
Technique  of  Cocainization  with  Schleich's  solution  : 

1.  Careful  sterilization  of  the  site  for  operation. 

2.  Xumbing  the  surface  with  ether  spray. 

3.  Hypodermic  injection  with  the  sterilized  solution  until  a  wheal 
about  five-eighths  iuch  in  diameter  is  raised. 

4.  Repeat  injections  at  the  margins  of  the  wheal  successively  until 
the  extent  of  the  anaesthesia  equals  the  extent  of  the  proposed  incision. 
After  the  first  puncture  there  is  little  or  no  pain  ;  the  anaesthesia  lasts 
about  ten  minutes. 

Central  Anaesthesia  by  Cocaine. — A  2  per  cent,  solution  of 
cocaine  sterilized  by  heating  to  80°  C.  three  times  on  consecutive  days, 
if  injected  into  the  arachnoid  space  of  the  spinal  cord  by  means  of  a 
sterilized  hypodermic  syringe,  will  produce  surgical  anaesthesia  (or 
perhaps,  more  properly  speaking,  analgesia)  of  all   structures  below 


MINOR   OPERATIONS.  101 

the  diaphragm.  The  dose  of  the  solution  varies,  according  to  the 
weight  of  the  patient,  from  1.5  c.c.  to  2  c.c.  Under  central  anaes- 
thesia by  cocaine  major  operations,  including  hysterectomy,  have  been 
performed  successfully.  The  method  is  said  to  be  especially  applic- 
able to  cases  in  which  ether  and  chloroform  are  contraiudicated  by 
cardiac,  pulmonary,  or  kidney  lesions.  Central  cocainization  obvi- 
ously demands  the  most  scrupulous  asepsis  to  avoid  the  disastrous 
results  of  infection  in  the  arachnoid  space.  The  utility  and  safetv  of 
this  method  have  yet  to  be  demonstrated. 

Adrenalin  alone  or  in  combination  with  cocaine  gives  excellent 
results;  it  should  be  used  in  0.1  per  cent,  solution  (1  :  1000),  of  which 
3  drops  may  be  employed  in  each  hypodermic  injection  of  cocaine  or 
it  may  be  applied  alone  externally  on  mucous  membranes. 

Anaesthesia  by  Salt  Water. —  The  hypodermic  use  of  aqueous 
salt  solution  (2  per  cent.)  is  said  to  produce  surgical  anaesthesia,  and, 
therefore,  to  be  a  satisfactory  substitute  for  the  weaker  solutions  of 
Schleich.  The  painless  removal  of  hemorrhoids  under  this  method 
of  anaesthesia  has  been  reported. 

INSTRUMENTS. 

Sims'  speculum  and  Simon's  speculum  have  been  described  in  the 
chapter  on  Diagnosis.  For  operations  on  the  vaginal  walls,  such  as 
the  closure  of  vaginal  fistulae,  repair  of  the  lacerated  cervix,  division 
of  the  cervix,  dilatation  of  the  cervix,  and  curettage,  Sims'  speculum 
is  regarded  generally  by  all  who  have  familiarized  themselves  with 
its  use  as  the  preferable  instrument.     See  Chapter  III. 

Simon's  speculum,  though  for  plastic  vaginal  work  often  inferior  to 
Sims',  is  yet  for  some  purposes  a  more  practical  instrument.  It  has 
one  advantage  over  Sims' — /.  e.,  the  patient  being  in  the  dorsal  posi- 
tion, on  a  Kelly  pad  or  rubber  sheet,  the  operation  may,  with  Simon's 
speculum,  be  done  under  constant  vaginal  irrigation. 

Simon's  instrument  and  the  dorsal  position  are  superior  to  Sims' 
and  the  lateroprone  position  for  all  operations  in  which  the  pelvic 
cavity  is  to  be  opened  through  the  vagina,  such,  for  example,  as 
vaginal  hysterectomy,  vaginal  salpingectomy,  and  vaginal  ovariotomy. 

Vulsella  forceps  similar  in  construction  to  those  shown  in  Figure 
45,  are  useful  in  various  operations  on  the  uterus  and  about  the  cervix. 
They  serve  to  grasp  and  draw  down  the  cervix,  to  grasp  an  intra- 
uterine tumor,  and  to  steady  the  cervix  during  the  })assage  of  a  suture 
or  during  curettage. 

Scissors. — The  minor  gvnecological  operations  may  be  performed 
either  with  the  scissors  or  with  a  knife.  The  choice  depends  much 
upon  the  education  and  habits  of  the  operator.  The  scissors  cause 
less  hemorrhage,  and  when  one  becomes  accustomed  to  their  use  he 
can  work  more  accurately  and  more  rapidly.  Any  strong,  well-made, 
slightly  curved  scissors  will  suffice,  but  those  of  Emmet  are  adapted 
especially  to  intravaginal,  perineal,  and  vulvar  operations. 

Emmet's  slightly  and  fullv  curved  scissors  are  almost  indispens- 
able   for   denuding   in    plastic    operations,   Figure    43 ;    the    slightly 


102 


GENERAL  PRINCIPLES. 

FlGtJEE  42. 


J      K       t       m 


MINOR   OPERATIONS.  103 

curved  are  used  for  perineal  and  for  ordinary  intra  vaginal  denudation  ; 
the  strongly  curved  are  convenient  for  denuding  a  strip  high  up  across 
the  vagina  or  cervix  uteri  in  fistula  and  cervix  operations.  These 
scissors  are  curved  toward  the  left,  and  are  intended  to  be  used  in  the 
right  hand.  Emmet  mentions  also  two  others,  Avith  curves  to  the  right ; 
but  it  is  scarcely  possible  to  imagine  an  operation  in  which  the  latter 
would  be  necessary.  In  ordering  these  scissors  one  should  be  careful 
to  explain  that  he  wants  those  which  are  curved  to  the  left  for  use 
in  the  right  hand ;  otherwise  the  instrument-maker  will  send  those 
which  curve  to  the  right  for  use  in  the  left  hand.  In  fact,  a  good  deal 
of  confusion  has  arisen  in  this  matter,  and  consequently  orders  often 
are  filled  with  scissors  which  are  useless. 

Sponge -holders. — Ordinary  hajmostatic  forceps  with  handles  eight 
inches  long  serve  the  purpose  of  sponge-holders  much  better  than 
instruments  made  expressly  for  the  purpose. 

Uterine  Tenaculum. — Numerous  tissue-forceps  have  been  devised 
for  grasping  the  tissues  to  be  denuded  or  excised,  but  a  properly 
constructed  tenaculum  in  the  educated  hand  is  the  most  convenient 
and  effective  instrument  for  this  purpose.  With  the  tenaculum  the 
operator  can  pick  up  and  hold  a  smaller  amount  of  tissue,  and  there- 
fore can  denude  more  superficially  than  is  possible  with  the  tissue- 
forceps.  The  instrument.  Figure  43,  has  a  perfectly  straight  hook  a 
little  more  than  a  quarter  of  an  inch  long  and  bent  at  right  angles  to 
the  shaft.  It  should  be  so  strong  and  stiff  that  considerable  force  may 
be  applied  in  the  line  of  the  instrument  without  breaking  or  bending 
the  hook,  or  in  a  lateral  direction  without  bending  the  shaft.  The 
uterine  tenaculum  is  useful  not  only  in  denudation,  but  also  in  almost 
every  step  of  a  gynecological  examination  or  operation.  In  some 
operations  as  many  as  four  of  them  may  be  required. 

WHEN  TO  OPERATE. 

Although  it  is  a  general  rule  not  to  operate  during  menstruation, 
it  has  by  no  means  been  proved  that  operations  are  more  dangerous 
during  this  period.  When  menstruation  is  so  long  continued  or  so 
profuse  as  to  endanger  life  or  health,  immediate  operation  may  be  im- 
perative. The  presence  of  menstrual  fluid,  however,  is  unfavorable, 
though  usually  not  a  bar  to  union  by  first  intention  in  a  uterine  opera- 
tion. An  operation  performed  immediately  upon  the  close  of  men- 
struation might  cause  it  to  reappear ;  if  too  near  the  anticipated 
period,  it  might  excite  a  premature  flow.     One  may  operate  safely 


Explanation  of  Figure  42. 

a.  Ligature  applied  in  this  manner  may  slip.     Reduced  one-half. 

b.  Ligature  applied  in  this  manner  cannot  slip.     Catgut  tied  in  this  manner  not 

apt  to  become  loose.     Reduced  one-half. 

c.  The  force])s  grasping  the  needle  over  the  eye  is  apt  to  crush  it. 

(1.  The  forceps  grasping  the  needle  in  this  way  does  not  hold  it  firmly. 

e.  Correct  grasp. 

/,  g,  h,  I.  Diiferent  forms  of  needles.     Ordinary  size. 

i,  k,  I,  m.  Needle-points  of  different  varieties,  magnified. 


104 


GENERAL  PRINCIPLES. 


between  the  third  day  after  the  close  of  one  jDeriod  and  the  tenth  day 
before  the  anticipated  appearance  of  the  next. 


Figure  43. 


EMMETS  NEEDLE   FORCEPS    j^SlZE,^ 


P 


A,  denuding  a  surface  with  Emmet's  curved  scissors  ;  B,  C,  suturing  a  wound. 

The  question  of  primary  or  secondary  operations  after  puerperal 
lacerations  has  been  much  discussed.  Emmet's  operation  for  lace- 
ration of  the  cervix,  unless  there  be  hemorrhage  from  the  torn  sur- 


MINOR   OPERATIONS.  105 

faces,  is  delayed  ordinarily  until  after  the  puerperium.  Many  suc- 
cessful cases  of  immediate  operation,  however,  have  been  reported. 
For  laceration  of  the  perineum,  however  extensive,  the  immediate 
operation  is  desirable  for  two  reasons :  The  torn  parts  can  be  adjusted 
accurately  to  their  former  relations,  which  is  almost  impossible  in 
the  secondary  operation  ;  and  the  operation,  if  well  performed,  gen- 
erally results  in  union,  and  therel)y  protects  the  patient  against 
septic  infection  through  the  torn  surfaces.  The  writer,  therefore, 
would  advise  the  primary  operation  of  perineorrhaphy  even  as  late  as 
two  days  after  delivery.  He  has  operated  repeatedly  on  the  second 
and  third  days,  and  once  on  the  ninth,  and,  with  scarcely  an  excep- 
tion, the  delayed  operation  has  resulted  in  satisfactory  union.  If, 
however,  the  primary  operation  has  been  delayed  for  a  number  of 
days,  it  is  best,  before  introducing  the  sutures,  to  denude  with  the 
curved  scissors  a  narrow  strip  all  around  and  over  the  torn  surfaces, 
in  order  that  fresh  surfaces  may  be  brought  together.  A  delay  of  a 
few  hours  after  labor  insures  greater  freedom  from  capillary  oozing, 
which  sometimes  occurs  after  closure  of  the  wound,  and  which  may 
prevent  union.  Moreover,  if  anaesthesia  be  required,  it  is  better  to 
wait  for  permanent  retraction  of  the  uterus ;  otherwise  the  ansesthetic 
may  cause  relaxation  and  consequent  uterine  hemorrhage. 

It  is  the  duty  of  the  accoucheur  at  the  close  of  the  puerperium  to 
examine  the  uterus,  vagina,  and  perineum,  and  to  repair  any  significant 
laceration  or  injury  before  evil  results  have  developed  from  it.  Opei'a- 
tions  may  be  necessary  even  during  lactation.  The  child  should  be 
kept  from  the  breast  only  until  the  mother  has  recovered  fully  from 
the  ansesthetic. 

Operations  during  Pregnancy  should  be  restricted  to  cases  of 
immediate  and  urgent  necessity.  Plastic  operations,  as  a  rule,  may 
be  deferred.  Tumors  connected  with  the  reproductive  organs,  such  as 
carcinoma  of  the  cervix  uteri,  ovarian  cyst,  uterine  polypi,  vaginal 
tumors,  vidvar  and  rectal  tumors,  may  have  to  be  removed.  The 
danger  of  abortion  following  operations  during  pregnancy  is  due 
chiefly  to  possible  sepsis  or  to  some  other  form  of  toxaemia ;  even  the 
toxsemia  of  diffusible  poisons  and  drugs,  such  as  iodine,  carbolic  acid, 
bichloride  of  mercury,  quinine,  and  the  bromides,  may  induce  abor- 
tion ;  hence  the  use  of  such  drugs  should  be  limited  and  judicious. 

Multiple  Operations. — When  several  operations  are  necessary,  it 
may  be  proper  to  perform  them  at  one  sitting.  A  rapid  operator  may 
])erform  safely  dilatation  of  the  uterine  canal,  curettage,  trachelor- 
rhaphy, elytrorrhaphy,  ])erineorrhaphy,  and  the  removal  of  hemor- 
rhoids at  one  time.  This  amount  of  operating  at  one  sitting  would 
hardly  be  permissible  for  a  slow  operator  or  a  beginner.  The  dura- 
tion of  an  operation  should  usually  be  less  than  an  hour  and  a  half  or 
two  hours.  Abdominal  section  or  vaginal  section  is  combined  some- 
times with  plastic  vaginal  work.  This  combination,  except  in  the 
hands  of  a  rapid  and  expert  operator,  is  not  approved. 


106  GENERAL  PRINCIPLES. 

PLASTIC  OPERATIONS. 

The  subject  of  plastic  operations  comprehends  all  operations  for 
the  repair  of  lacerations  of  the  cervix  and  perineum,  and  of  vaginal 
fistulffi ;  it  also  includes  certain  operations  on  the  vaginal  walls 
known  as  elytrorrhaphy,  and  numerous  operations  on  the  urethra, 
vulva,  and  anus. 

A  clear  appreciation  of  the  causes  of  failure  will  contribute  to 
success  in  plastic  surgery.  Two  principal  causes  of  failure  are :  first, 
parts  which  never  ought  to  be  united  are  brought  often  into  appo- 
sition ;  second,  faulty  technique  may  result  in  failure  of  union. 

One  of  the  most  common  bad  results  of  the  repair  of  the  lacerated 
cervix  uteri  or  perineum,  for  example,  is  the  union  of  parts  which 
were  not  together  before  the  injury,  and  cannot  be  united  without 
harm.  Commonly  a  plastic  operation  which  results  in  union  is  called 
successful.  If,  however,  there  has  been  union  of  wrong  parts,  actual 
harm  may  have  been  done.  The  flap-splitting  operation  of  perineor- 
rhaphy, for  example,  too  often  gives  such  a  result. 

Union  by  First  Intention  will  result  almost  always  from  a  cor- 
rect operation.  True,  in  certain  cases  of  vaginal  fistula  in  which 
there  has  been  great  loss  of  tissue  from  sloughing,  failures  may  arise 
from  the  cicatricial  character  of  the  parts  or  from  difficulty  in  hold- 
ing the  edges  together.  In  very  fat  subjects  perineorrhaphy,  espe- 
cially when  the  rupture  extends  through  the  sphincter  ani  muscle, 
may  fail  even  after  the  most  skilful  operation.  Certain  systemic 
diseases,  among  them  diabetes,  are  imfavorable  for  union.  Generally 
the  conditions  of  success  are  within  the  control  of  the  operator.  He 
should  'put  the  parts  to  he  united  in  such  a  condition  that  non-union 
would  be  contrary  to  nature.  These  conditions  are  simple,  but  ab.so- 
lute ;  and  the  operator  who  has  neglected  them  can  neither  fairly 
attribute  his  failure  to  the  debilitated  state  of  the  patient,  nor  to 
chance,  nor  to  accident.  Indeed,  union  almost  invariably  follows 
if  the  surfaces  to  be  united  are  prepared  properly  and  kept  in  contact 
for  a  week.  The  first  condition,  asepsis,  has  been  discussed.  The 
others  will  be  presented  in  the  following  paragraphs. 

Denudation. — The  patient  having  been  etherized,  placed  in  posi- 
tion, and  the  field  of  operation  exposed,  the  surfaces  to  be  united 
should  be  denuded.  Correct  denudation  is  a  prerequisite  to  healing 
by  first  intention.  Surfaces  to  be  united  should  be  so  denuded  that 
when  brought  together  they  will  fit  accurately,  otherwise  a  part  of 
the  denuded  surface,  being  in  contact  with  an  undenuded  surface, 
must  heal  by  granulation  and  suppuration,  which  may  irritate  the 
rest  of  the  wound  excessively,  and  always  produces  cicatricial  tissue, 
which  is  very  objectionable.  The  denuded  surface  should,  moreover, 
be  smooth  and  free  from  shreds,  which  might  die  and  become  sources 
of  septic  infection.  Every  particle  of  membrane  or  skin  within  the 
area  of  denudation  should  scrupulously  be  removed.  If  the  surface 
be  perfectly  healthy,  the  more  superficial  the  denudation  the  better ; 
but  diseased  and  cicatricial  tissues  do  not  unite  readily,  and  should 
therefore,  when  practicable,  be  removed. 


MINOR   OPERATIONS.  107 

Figure  43  shows  the  action  of  the  tenacuhim  and  scissors  in 
denuding.  The  superiority  of  the  tenaculum  as  a  substitute  for  the 
tissue-forceps  must  become  apparent  to  any  one  who  will  familiarize 
himself  with  its  use. 

Needles. — A  round  needle  is  preferable  to  one  with  a  cutting  edge. 
The  incised  wound  made  by  the  latter  is  generally  too  large  for  the 
suture,  bleeds  freely,  is  prone  to  suppurate,  and  requires  more  time 
for  healing.  The  punctured  wound  made  by  the  former  readily 
shrinks  down  upon  the  suture,  is  less  liable  to  bleed  or  to  suppurate, 
and,  after  removal  of  the  suture,  heals  more  quickly.  The  tissue, 
especially  in  the  cervix  uteri,  is,  however,  often  so  dense  as  to  neces- 
sitate the  use  of  a  needle  with  a  cutting  edge. 

Many  of  the  most  dexterous  operators  prefer  the  straight  needle 
to  the  curved.  The  straight  needle  has  two  advantages  :  first,  how- 
ever deeply  it  may  be  buried  in  the  tissues,  the  position  of  its  point 
can  always  be  determined  from  its  direction  and  length  ;  second,  the 
force  necessary  to  introduce  it  being  in  the  direction  of  the  needle,  it 
is  much  less  than  that  required  to  introduce  a  curved  needle,  for  that 
force  must  be  applied  on  the  tangent  to  the  curve ;  hence,  the 
thickness  of  the  curved  needle  must  be  greater  in  order  to  avoid 
breaking.  The  straight  needle,  in  a  word,  requires  less  force  for  its 
introduction,  is  less  liable  to  break,  and  makes  a  smaller  wound. 
The  plain  round  point,  however  sharp,  sometimes  encounters  great 
resistance  in  passing  through  dense  tissues.  The  trocar  point  or  the 
saddle  point  represented  in  Figure  43  is  less  objectionable  than  the 
cutting  edge,  and  may  be  introduced  almost  as  easily. 

Various  needles  with  handles  attached  or  detached,  and  of  differ- 
ent curves  and  shapes,  have  been  devised,  some  with  eyes  at  their 
points,  some  without  eyes,  and  others  of  cylindrical  form,  through 
which  the  suture  is  passed  lengthwise  from  one  end  to  the  other. 
They  complicate  rather  than  simplify  an  operation,  and  are  in  no 
respect  superior  to  the  simple  needle  and  thread. 

How  to  Handle  a  Needle-forceps. — The  simple  rotation  of  the 
needle-forceps  on  its  long  axis  by  a  turn  of  the  wrist  enables  the 
operator  to  sweep  the  straight  needle  around  a  curve  in  the  vertical 
plane,  or  it  may  be  carried  around  a  curve  in  the  horizontal  plane  by 
loosening  and  tightening  the  forceps  grasp  upon  the  needle  at  very 
short  intervals,  so  that  the  angle  between  the  forceps  and  the  needle 
may  change  almost  constantly  during  the  passage  of  the  needle.  In 
this  way  the  straight  needle  may  be  made  to  carry  a  suture  around  a 
curve  more  accurately  than  the  curved  needle,  and  often  more  easily. 
Obviously,  the  lock  forceps,  which  do  not  permit  of  this  freedom  of 
motion,  are  unsuited  to  such  manipulations.  Figure  43  represents 
Emmet's  needle-forceps  without  lock. 

The  Application  of  Sutures. — The  most  practical  materials  for 
sutures  are  silkworm-gut  and  catgut.  The  peculiar  advantages  of 
each  will  be  jiresented  in  the  description  of  special  operations.  Be- 
fore the  introduction  of  the  sutures  approximate  the  denuded  surfaces 
with  tenacula  to  determine  whether  they  are  of  such  size  and  shape 
that  the  union  will  produce  the  desired  result,  and  wdiether  accurate 


108 


GENERAL  PRINCIPLES. 


coaptation  of  the  margins  can  be  secured  without  undue  traction, 
which  might  cause  the  suture  to  cut  out ;  then  hook  up  the  margin 
of  the  wound  with  a  tenacuhmi,  introduce  tlie  needle,  and  apply 
counterpressure,  Figure  43,  C,  B,  until  the  needle-point  can  be  seized 
and  drawn  through  with  the  forceps.  Some  operators  use  the  blunt 
hook  for  counterpressure ;  but  a  strong  tenaculum  which  will  neither 
break  nor  bend  is  preferable,  especially  in  dense  uterine  tissue,  because 
it  may  also  be  fixed  in  the  tissues  at  the  very  point  where  the  operator 
desires  to  force  the  needle  through,  and  it  thereby  insures  greater  pre- 
cision in  directing  the  needle  to  the  point  of  exit. 

Figure  44. 


Removing  a  suture. 


In  making  counterpressure  the  tenaculum  may  sli])  and  the  uterus 
receive  a  violent  and  sudden  jerk,  which  is  not  witliout  danger,  espe- 
cially when  often  repeated ;  this  may  be  avoided  and  the  operation 
facilitated  by  holding  the  flap  in  the  vulsellum  forceps  while  the 
needle  is  being  forced  through  between  its  teeth. 

Sutures  should  be  about  one-fourth  of  an  inch  apart,  should  include 
considerable  tissue,  and,  if  practicable,  should  pass  entirely  under,  not 
through,  the  denuded  surface,  so  as  not  to  be  in  contact  with  any  por- 
tion of  the  wound.  When  at  a  distance  from  the  denuded  surface 
they  are  less  liable  to  irritate  and  give  rise  to  swelling  and  infection. 


MINOR   OPERATIONS.  109 

The  sutures  should  be  tied  with  the  greatest  care,  and  shoukl  be 
drawn  just  tightly  enough  to  hold  the  denuded  surfaces  in  contact. 
If  drawn  too  tightly,  the  tissue  will  become  strangulated  and  swollen, 
the  sutures  will  cut  out,  and  the  operation  may  fail. 

Before  tying  a  suture  the  bleeding  should  be  stopped  ;  otherwise 
small  quantities  of  blood  may  accumulate  in  the  track  of  the  wound 
and  serve  as  a  mechanical  bar  to  union.  A  constant  stream  of  hot, 
sterilized  water  playing  on  the  wound  during  the  tying  of  the  sutures 
is  desirable. 

The  After-treatment  will  be  presented  under  the  special  subjects. 
Generally  speaking,  the  field  of  operation  is  to  be  kept  clean  and 
immobile. 

Removal  of  Sutures. — Ordinarily  the  sutures  should  be  removed 
at  the  end  of  a  period  varying  from  ten  to  fifteen  days  ;  if  suppura- 
tion occur,  earlier.  Sutures  about  the  vulva  and  perineum  should  be 
removed  in  about  ten  days.  If  left  much  longer,  they  may  become 
loose  or  cause  suppuration.  In  the  vaginal  walls  they  may  be  left 
several  days  longer.  In  the  cervix,  where  suppuration  seldom  occurs, 
they  should  be  removed  in  about  two  weeks,  unless  perineorrhaphy 
has  been  done  at  the  same  time,  in  which  case  removal  cannot  safely 
be  undertaken  in  less  than  three  or  four  weeks.  To  remove  a  suture, 
seize  the  free  end  with  a  forceps,  and  with  the  scissors  cut  the  nearest 
side  of  the  loop.  See  Figure  44.  Cutting  the  nearest  side  tends  to 
hold  the  edges  of  the  freshly  united  wound  together  during  the  with- 
drawal of  the  suture ;  if  the  loop  were  cut  on  the  farther  side,  removal 
would  tend  to  reopen  the  wound.  It  is  well  to  seize  with  the  forceps 
only  one  of  the  free  ends,  for  the  other  will  then  be  available  in  case 
this  one  is  cut  oiF  accidentally.  Always  make  sujfficient  traction  to 
bring  the  loop  in  sight  before  cutting,  otherwise  both  sides  may  be 
cut  otf  below  the  knot  and  the  loop  left.  If  then  the  ends  of  the 
loop  retract,  as  they  usually  do,  the  loop  may  remain  indefinitely, 
keep  up  constant  suppuration,  and  finally  have  to  be  removed  under 
ansesthesia  by  incision. 

Assistants. — Four  assistants  usually  are  required  for  a  gyneco- 
logical operation — one  to  give  the  ether,  one  at  the  operator's  left, 
to  hold  the  speculum,  and  one  at  the  operator's  right,  to  sponge,  and 
one  to  thread  needles  and  render  other  assistance.  If  the  operation  be 
on  the  perineum  or  vulva,  and  the  patient  be  in  the  dorsal  decubitus, 
the  thighs  must  be  flexed  and  held  in  the  lithotomy  position  by  the 
two  assistants  on  the  right  and  left.  The  assistants  in  charge  of  the 
ether  and  sponging  should  be  physicians.  The  holding  of  the  specu- 
lum and  threading  of  needles  are  better  done  by  nurses. 


DILATATION  OF  THE  UTERUS. 

The  cavity  of  the  uterus  may  be  made  surgically  accessible  to  the 
examining  finger  or  to  instrumentation  by  dilatation.  The  indications 
for  dilatation  may  be  diagnostic  or  therapeutic,  or  both.  Among 
these  indications  are  stenosis  or  stricture  of  the  canal,  uterine  hemor- 


110 


GENERAL  PRINCIPLES. 


rhage  due  to  endometritis,  neoplasms,  abortions,  and  pathological  ante- 
flexions.     The  means  and  methods  are  these  : 

1.  Incision. 

2.  Tents. 

3.  Graduated  bougies  or  sounds. 

4.  Instruments  with  diverging  blades. 

1.  Incision  of  any  portion  of  the  uterine  canal  may  be  required  in 
order  to  render  the  endometrium  accessible  for  instrumental  or  manual 
interference.  But  incision  is  especially  applicable  to  the  lower  part 
of  the  cervical  canal  and  to  the  external  os,  and  is  performed  for 
congenital  or  acquired  stenosis.  Its  object  is  to  insure  the  free  out- 
flow, not  only  of  menstrual  fluid,   but  also  of   the  uterine  mucus, 


Figure  45. 


Incision  of  the  cervix  uteri  with  straight  scissors ;  the  cervix  is  steadied  by  a  vulsella  forceps. 

which,  if  retained,  l)ecomes  offensive,  irritates  the  uterine  mucosa, 
and  causes  liypersecretion.  Oftentimes  the  uterine  secretions  are  so 
impeded  in  their  passage  through  the  strictured  os  internum  or  exter- 
num that  they  accumulate,  distend  the  uterine  cavity,  and  are  thrown 
off  at  irregular  intervals  Avith  expulsive  pains  simulating  labor-pains. 
This  explains  certain  cases  in  Avhich  there  is  a  recurrence  in  the  inter- 
menstrual period  of  all  the  painful  phenomena  of  obstructive  dys- 
menorrhoea. 

Schroeder's  Method. — Schroeder,  in  certain  cases,  especially  of  intra- 
uterine polypi,  incises  the  cervix  bilaterally,  seizes  the  po.sterior  lip  with 
a  vulsellum  forceps,  and,  with  his  finger  as  a  dilator,  works  his  way 
to  the  uterine  cavity.  The  uterus,  dilated  in  this  way  and  well  drawn 
down,  is  very  accessible.     Since   the  lateral  incisions  extend  into  a 


MINOR   OPERATIONS. 


Ill 


neighborhood  that  is  very  liable  to  infection,  the  safety  of  the  opera- 
tion must  depend  upon  thorough  asepsis.  In  a  rigid  uterus,  moreoyer, 
it  is  often  impracticable  to  incise  and  dilate  according  to  the  method 
of  Schroeder. 

The  Author's  Method  of  rendering  the   entire  uterine  cavity  and 
the    uterine    walls    accessible    for   surgical    operations,    such    as    the 


Figure  46. 


Dilatation  by  graduated  bougies.    Six  gradually  increasing  sizes  shown  in  the  three  instru- 
ments at  the  lower  part  of  the  illustration.    One  end  of  each  dilator  is  slightly  larger  than  the 

other. 


removal  of  myomata  through  the  vagina  by  free  median  incision  of 
the  anterior  uterine  \vall,  is  illustrated  and  described  under  the  Surcri- 
cal  Treatment  of  Myomata,  Chapter  XYII. 

2.  Tents. — Sponge,  tupelo,  and  sea-tangle  are  the  materials  of 


112  GENERAL  PRINCIPLES. 

which  tents  commonly  are  made ;  if  they  are  introduced  into  the 
uterus  in  the  dry,  compressed  state,  the  mucous  secretion,  stimulated 
by  their  presence,  causes  them  to  swell  laterally  to  the  extent  of  two 
or  three  diameters,  and,  correspondingly,  to  dilate  the  canal. 

The  danger  of  sepsis  after  continuous  dilatation  by  introducing  one 
tent  after  another  is  very  great.  Alarming  results  often  have  fol- 
lowed the  use  of  the  second  or  the  third  tent,  seldom  the  first.  A  tent 
should  not  under  any  circumstances  be  allowed  to  remain  in  the  uterus 
more  than  twelve  hours.  The  tents  furnished  by  instrument-makers 
are  usually  not  aseptic.  Before  using  them,  therefore,  it  is  always 
well  to  subject  them  to  the  dry-heat  process  of  Boeckmann,  as  described 
in  Chapter  II.  for  the  disinfection  of  catgut.  After  the  removal  of  a 
tent  the  endometrium  should  be  washed  out  with  sterile  water,  and 
disinfected  with  a  topical  application  of  a  strong  solution  of  iodine  in 
95  per  cent,  carbolic  acid ;  this  application  should  be  made  by  means 
of  an  applicator  wound  with  cotton.  The  danger  of  infection  from 
tents  is  so  great  that  the  use  of  them  generally  is  disapproved. 

3.  Graduated  Bougies. — The  uterus  may  be  dilated  by  means 
of  graduated  bougies.  Figure  46  shows  this  method  of  dilatation  ;  it 
is  adapted  particularly  to  cases  in  which  the  abdominal  walls  are  thin 
and  lax,  so  that  the  uterus  may  easily  be  fixed  by  the  hand  over  the  ab- 
domen, while  one  sound  after  another  is  forced  into  the  canal  until  the 
required  dilatation  is  accomplished.  If  the  abdominal  walls  are  thick 
and  tense,  it  is  necessary  to  use  Sims'  or  Simon's  speculum,  and  during 
dilatation  to  fix  the  cervix  with  the  vulsella  forceps,  but  in  such  cases 
the  forceps  are  apt  to  tear  out,  and  therefore  the  diverging  instruments 
are  preferable. 

4.  Diverging"  Instruments. — Innumerable  instruments  have  been 
devised  with  blades  which  diverge  and  dilate  the  uterus  when  the 
handles  are  pressed  or  screwed  together.     See  Figure  47. 

Wathen's  dilator.  Figure  47,  B,  is  the  most  serviceable.  These 
dilators  are  generally  too  heavy  to  be  inserted  until  the  way  has  been 
opsned  by  a  lighter  instrumcsnt,  like  Palmer's,  Figure  47,  A,  or  by  the 
smaller  graduated  sounds.  It  is  important  that  all  instruments  for 
powerful  dilatation  be  supplied  with  the  thumb-screw  for  screwing  the 
handles  together.  If  the  handles  are  compressed  with  the  hand, 
rupture  of  the  uterus  is  apt  to  occur.  The  smaller  dilator  of  Palmer 
does  not  require  the  screw. 

Extent  of  Dilatation. — Goodell  was  foremost  among  the  advocates 
of  forcible  dilatation.  In  a  large  experience  with  extreme  dilatation 
under  ether  he  had  no  fatal  result  and  no  serious  inflammatory  dis- 
turbance. He  carried  the  dilatation  to  three-fourths  of  an  inch  in  the 
thin-walled,  unyielding  infantile  uterus,  and  to  one  and  one-quarter 
inches  in  ordinary  cases.  In  case  of  a  rigid,  unyielding,  or  thin-walled 
uterus,  which  might  tear  from  rapid  expansion  of  the  dilating  blades, 
it  is  permissible  with  rigid  aseptic  care  to  begin  dilatation  with  a 
sponge-  or  tupelo-tent,  the  softening  influence  of  which  prepares  the 
canal  for  more  easy  and  thorough  dilatation  by  the  forcible  method. 

The  Dangers  of  Forcible  Dilatation  are  from  traumatism  and  sepsis. 
There  may  be  extensive  rupture  from  overdistention  by  rapid  dilata- 


MINOR   OPERATIONS. 


113 


tion  of  a  rigid  uterus,  and  dangerous  hemorrhage,  peritonitis,  and 
death  may  result.  A  uterus  raptured  by  dihitation  should  be  packed 
and  drained  by  aseptic  gauze.  An  abdominal  or  vaginal  section  may 
be  necessary  to  control  hemorrhage. 

It  would  be  a  mistake  to  suppose  that  antisepsis  deprives  dilatation 
by  any  method  of  all  its  perils.     All  manij)ulations  of  this  class  are 


Figure  47. 


Forcible  dilatation  of  the  uterus:  A,  Palmer's  dilator  in  use:  B,  Wathen's  dilator,  to  be 
used  for  continuing  the  operation ;  C,  anal  dilator  sometimes  useful  for  extreme  dilatation, 
especially  in  cases  of  abortion.    About  one-third  natural  size. 

dangerous,  and  not  to  be  employed  unless  the  indication  is  quite  clear. 
Existing  pelvic  inflammation,  acute  or  chronic,  is  a  serious  contra- 
indication. Indeed,  the  history  of  a  majority  of  fatal  cases  includes 
previous  cellulitis,  peritonitis,  or  metritis.  Dilatation,  however  slight, 
by  any  method,  should  be  regarded  as  a  surgical  operation,  should 
always  be  done  at  the  patient's  house  or  a  hospital,  never  at  the  office, 
and  should  be  followed  by  rest  in  bed  for  a  time  varying  from  one  to 


114 


GENERAL  PRINCIPLES. 


seven  days.  Forcible  dilatation,  either  by  sounds  or  by  diverging 
instruments,  except  when  the  dilatation  is  to  be  slight,  requires  an 
anaesthetic.  Tenderness  and  other  signs  of  inflammation  about  the 
uterus  contraindicate  the  operation. 

If,  in  performing  forcible  dilatation  of  a  rigid  cervix,  the  force 
required  suddenly  becomes  less,  the  operator  should  cease  dilating  at 
once,  for  the  lessened  resistance  usually  indicates  beginning  rupture. 

Special  Advantages  of  Each  Method  of  Dilatation. 

Incision. — Contraction  of  the  os  externum  and  lower  portion  of 
the  uterine  canal  is  treated  best  by  Schroeder's  operation  of  bilateral 
incision  of  the  cervix.     See  Treatment  of  Cervical  Endometritis. 

Tents. — Sponge-tents  are  the  most  dangerous,  tupelo  the  least. 
Laminaria  has  but  one  advantage  over  tupelo — flexibility  and  adapt- 
ability to  a  tortuous  canal.     In  a  case  of  rigid  hyperplastic  or  thin- 

FlGTJRE  48. 


Uterus  perforated  by  a  tupelo-tent.    Figure  to  left  shows  size  of  tent  before  and  after  expansion. 

walled  cervix  not  safely  dilatable  by  rapid  means,  the  tent  is  some- 
times permissible  as  a  means  of  preparation  for  rapid  dilatation  by 
graduated  sounds  or  diverging  instruments.  The  nse  of  it,  how- 
ever, even  in  careful  hands,  many  times  has  caused  fatal  pelvic 
infection. 

Graduated  Sounds  and  Diverging  Dilators  are  generally  the 
safest  and  most  effective  means  of  dilatation,  and  usually  should  have 
the  preference. 

One  may  combine  the  principle  of  graduated  sounds  in  the  use 
of  diverging  dilators.  This  requires  a  series  of  dilators  of  graduated 
sizes.  The  small  instrument  is  inserted  first,  and  the  blades  spread ; 
then  the  dilator  next  larger  is  used  in  the  same  manner ;  and  so  on 


MINOR   OPERATIONS. 


115 


through  the  series.  Before  spreading  the  blades  each  instrument  acts 
as  a  graduated  sound  ;  as  the  blades  diverge  they  act  on  the  principle 
of  the  glove-stretcher.  At  least  four  dilators  are  required  :  two  of 
the  Palmer,  and  two  of  the  Wathen  variety. 

A  small  light  dilator  as  a  means  of  complete  dilatation  has  two 
disadvantages  :  first,  the  light  blades  may  bend  and  fail  to  stretch  the 
canal  beyond  a  limited  degree ;  second,  if  they  do  not  spring  or  bend, 
they  are  apt  to  imbed  themselves — that  is,  crush  their  way  into  the 
uterine  walls.  The  result  is  not  dilatation  by  stretching,  but  by  tear- 
ing. The  wound  thus  inflicted  may  be  dangerous.  This  unfor- 
tunate result  may  l)e  avoided  by  the  use  of  a  graduated  series  of 
instruments. 

Technique  of  Forcible  Dilatation. — ^^1.  Disinfect  the  vagina  and 
vulva.     2.  Expose  the  cervix  by  a  Sims  or  a  Simon  speculum.     3. 

Figure  49. 


Examination  of  the  dilated  uterus  by  conjoined  digital  touch. 

Grasp  the  cervix  firmly  in  the  teeth  of  a  vulsellum  forceps.  Figure 
47.  4.  Introduce  the  successive  dilators  and  slowly  screw  the  blades 
apart.  5.  Wash  out  the  uterine  cavity  with  sterilized  Avater  from  a 
fountain-syringe  through  a  rubber  tube  and  canula.  The  ordinary 
glass  female  catheter  is  a  good  canula.  The  dilatation  should  be  suf- 
ficient to  give  a  free  return  flow  by  the  side  of  a  single  canula.  Dur- 
ing the  washing-out  it  is  well  to  remove  and  reintroduce  the  canula 
every  two  or  three  seconds  alternately  to  prevent  injection  of  a  pos- 
sibly patulous  Fallopian  tube.  See  Treatment  of  Endometritis  in 
Chapter  XVII. 

CURETTAGE. 

The  diagnostic  significance  of  the  curette  has  been  given  in  Chapter 
III.     The  therapeutic  purpose  is  the  removal  of  diseased  tissue  or 


116 


GENERAL  PRINCIPLES. 


foreign  bodies  from  the  interior  of  the  uterus.  The  symptomatic 
indications  are  usually  hemorrhage,  uterine  discharges,  or  infection 
due  to  some  intra-uterine  cause.  The  instrument  first  was  used  in 
1843  by  Recamier ;  it  has  passed  through  numerous  modifications, 
and  on  account  of  the  disastrous  results  that  have  followed  the  use  of 


Figure  50. 


TECHNIQUE 

OF      CURETTAGE 


PLACENTAL 


Technique  of  curettage ;  varieties  of  curettes ;  placental  forceps.    One-third  natural  size. 

it — perforation  of  the  uterus,  metritis,  salpingitis,  cellulitis,  perito- 
nitis— it  has  received  at  times  the  severest  censure,  not  wholly 
undeserved. 

The  dull  curette,  shown  in  Figure  50,  is  made  of  flexible  copper 
wire.  The  loop  has  slightly  flattened  but  not  cutting  edges ;  the 
malleable  shank  may  be  bent  like  a  probe  to  conform  to  the  direction 
of  the  uterine  canal.     Whatever  the  force  applied,  it  is  not  likely  to 


MINOR   OPERATIONS.  Ill 

injure  the  sound  tissue,  although  it  will  remove  loose  foreign  bodies, 
such  as  the  secundines  of  abortion. 

The  sharp  curette,  shown  in  Figure  50,  is  designed  to  remove  such 
diseased  tissues  as  are  connected  more  intimately  with  the  uterus ;  for 
example,  an  infected  endometrium  or  a  malignant  growth.  The  loop 
is  of  steel,  and  has  a  sharp  cutting-edge.  The  shank  is  of  flexible 
copper,  and  may  be  bent  to  conform  to  the  direction  of  the  uterine 
canal. 

The  following  is  a  summary  of  the  indications  for  the  use  of  the 
curette  : 

I.  For  diagnosis  of — 

a.  New  growths  of  the  uterus — fibroids,  carcinoma,  sarcoma, 

deciduoma  malignum. 

b.  Inflammatory  products — endometritis. 

c.  Retained  products   of  conception — placenta,  foetus,  hydatid 

mole,  fleshy  mole. 

II.  For  therapeutic  purposes  in  cases  of — 

a.  Endometritis. 

b.  Mucous  polypi. 

c.  Inoperable  malignant  growths. 

d.  Hemorrhage  in  inoperable  fibroids. 

e.  Foreign  bodies,  such  as  secundines  of  abortion. 
The  dangers  of  the  curette  are  in  causing : 

1.  Septic  infection. 

2.  Perforation  of  the  uterus. 

8.  Hemori'hage  in  cases  of  malignancy. 

4.  Hemorrhage  and  abortion  in  cases  of  unsuspected  pregnancy. 

5.  Permanent  destruction  of  the  endometrium  by  scraping  too 

much. 
Technique  of  Curettage. — The  steps  of  curettage  are  these  (see 
Chapter  XVII.) : 

1.  Dilate  through  a  speculum  sufficiently  for  the  easy  admission  of 
the  curette.     Figure  47. 

2.  Steady  the  cervix  with  the  vulsellum  forceps  and  introduce  the 
curette.     Figure  50. 

3.  Should  the  object  be  to  remove  some  foreign  body,  the  dull 
curette  will  accomplish  this  readily  if  used  like  a  rake.  Little  force 
is  required.  The  sensation  imparted  to  the  fingers  will  show  whether 
all  the  foreign  substance  has  been  removed — i.  e.,  w'hether  the  loop 
glides  over  a  smooth  surface. 

4.  If  the  object  be  to  remove  diseased  tissue,  the  sharp  curette 
should  be  used  with  a  back-and-forth  scraping  motion  round  and 
round  the  endometrium.  The  operator  will  know  when  the  tissue 
has  been  removed  sufficiently  :  first,  by  the  fact  that  no  more  comes 
away ;  second,  by  the  sensation  which  the  curette  im])arts  to  the 
fingers,  of  a  hard,  resisting,  more  or  less  healthy,  intra-uterine  surface. 

5.  The  diseased  tissue  having  been  scraped  away,  the  endometrium 
should  be  washed  out  with  sterilized  water. 

6.  If  it  is  desirable  to  apply  a  medicinal  substance,  such,  for 
example,  as  a  saturated  solution  of  iodine  crystals  in  pure  carbolic 


118 


GENERAL  PRINCIPLES. 


acid,  this  may  be  done  by  means  of  an  applicator  or  a  fine  dressing- 
forceps  wound  with  absorbent  cotton.  Before  making  the  application, 
pack  absorbent  cotton  under  the  cervix,  to  absorb  any  fluid  which 
otherwise  might  run  out  and  irritate  the  vagina. 

7.  The  after-treatment  is  rest  in  bed  for  a  week,  with  vaginal 
douches  twice  daily  of  some  disinfectant  such  as  0.5  per  cent,  solution 
of  lysol  in  sterilized  water. 


THE  STAFFORDSHIRE  KNOT. 


It  is  sometimes  necessary  in  minor  and  major  operations  to  apply 
a  ligature  en  masse.     In  many  cases  this  ligature  may  to  great  advan- 


FlGUBE  51. 


Technique  of  the  Staffordshire  knot.    One-third  natural  size. 

tage  take  the  form  of  the  Staffordshire  knot.    This  knot  will  be  found 
especially  applicable  to  the  ligating  of  hemorrhoids.     The  applica- 


MINOR   OPERATIONS.  119 

tion  of  it,  Figure  51,  is  as  follows :  The  part  to  be  ligated  is  trans- 
Hxecl  with  the  needle  and  the  needle  withdrawn  so  as  to  leave  the  loop 
of  the  thread  on  the  farther  side  of  the  stump  a.  The  loop  then  is 
drawn  over  the  mass  to  be  ligated  and  one  of  the  free  ends  drawn 
through,  so  that  one  free  end  is  under  and  the  other  over  the  retracted 
loop,  6  and  c ;  both  free  ends  being  seized  by  the  right  hand  are  drawn 
tightly  through  the  mass  while  the  thumb  and  forefinger  of  the  left 
hand  grasp  the  ligature  where  the  free  ends  cross  the  loop  and  make 
firm  counterpressure  against  the  mass  until  complete  constriction  is 
secured,  d.  Finally  the  ligature  is  tied  securely,  e.  It  then  may  be 
passed  around  the  pedicle  and  tied  again.  The  advantages  of  the 
knot  are:  1,  it  ties  the  pedicle  in  two  halves;  2,  these  halves  are 
uniformly  and  strongly  compressed  into  one  mass.  It  is  quite  essen- 
tial to  draw  the  ligature  very  tight  and  to  retain  the  constriction 
thereby  secured  until  the  knot  is  tied. 


CHAPTER   VI. 


MAJOR  OPERATIONS. 


This  chapter  is  a  general  consideration  of  those  procedures  which 
are  common  to  the  opening  of  the  peritoneal  cavity.  Peritoneal  sec- 
tion may  be  made  through  the  abdominal  walls  or  through  the  vagina ; 
hence  the  subject  is  divided  into 

1.  Abdominal  section. 

2.  Vaginal  section. 


1.  ABDOMINAL  SECTION. 

Operating"- tables. — The  table  already  described  for  examination 
and  for  vaginal  operations  will  suffice  for  abdominal  section,  if  length- 
ened so  that  the  patient  may  lie  upon  it  at  full  length.  For  this  pur- 
pose a  short  table  may  be  supplanted  by  a  stand  or  by  another  shorter 
table. 

Figure  52. 


Trendelenburg  position  :  table  improvised. 


The  Trendelenburg-  Position. — A  favorite  table  for  hospital  use, 
and  especially  for  abdominal  section,  is  that  of  Trendelenburg  or  some 
modification  thereof.  The  top  of  the  table  may,  at  any  time  during 
an   operation,  be  adjusted  readily  to  any  desired  angle,  and  by  this 


1:20 


MAJOR   OPERATIONS. 


121 


means  the  hips  may  be  elevated  so  as  to  cause  the  intestine  to  gravi- 
tate away  from  the  pelvis  toward  the  diaphragm.  The  surgeon  may 
then  gain,  in  favorable  cases,  an  almost  unobstructed  view  of  the  pel- 
vic basin  and  may  work  deep  in  the  pelvic  cavity  unimpeded  by  the 
distended  intestine.  It  is  even  maintained  by  advocates  of  this  posi- 
tion that  in  these  favorable  cases  the  operation  may  be  proceeded  with 
as  readily  as  if  it  were  on  the  external  surface.  Extravagant  claims 
are  made  that  this  position  makes  pelvic  surgery  easy,  so  that  an 
indifferent   operator   may  undertake   it  safely.     The  table  is  useful 

FiGL'KE   53. 


Ordinary  gauze  sponges  held  by  a  retractor  to  keep  the  intestines  out  of  the  operator's  way. 


during  angesthesia  Avhen  the  pulse  and  respiration  fail  and  it  becomes 
desirable  to  elevate  the  lower  extremities  and  lower  the  head. 

The  advantages  of  this  position,  although  admitted,  should  not  be 
overestimated.  Besides  the  fact  that  in  many  cases  the  field  of  oper- 
ation is  not  rendered  more  accessible,  the  position  has  several  disad- 
vantages :  first,  infectious  fluids  which  escape  during  the  operation  are 
certain  to  gravitate  toward  the  diaphragm,  and  may  infect  the  general 
peritoneum  ;  second,  the  abdominal  muscles  often  are  made  more  rigid. 
The  Trendelenburg  position  does  not  overcome,  but  rather  lessens, 
a  few — only  a  few — of  the  difficulties  and  dangers  of  abdominal 
surgery.    With  the  patient  on  an  ordinary  table,  large  gauze  pads  may 


122  GENERAL  PRINCIPLES. 

be  used  in  such  a  way  as  to  keep  the  intestine  out  of  the  way,  and 
thereby  to  render  accessible  the  deeper  parts  of  the  pelvis. 

Improvised  Substitute  for  the  Trendelenburg  Table. — The  end  of  a 
common  table  may  be  raised  on  a  block  or  chair  so  as  to  give  it  the 
required  slant.  The  patient  then,  with  the  legs  hanging  over  the  foot 
of  the  table,  may  readily  be  adjusted  to  the  desired  angle  without 
recourse  to  the  more  or  less  complicated  Trendelenburg  table. 

The  Preparatory  Treatment. — The  necessary  antiseptic  pro- 
cedures to  an  aseptic  result  have  been  set  forth  in  Chapter  II.  After 
the  patient  is  on  the  table  and  under  ansesthesia  it  is  well  to  scrub  the 
abdomen  again  with  the  sterilized  soap  and  water,  then  wash  with 
clean  water,  then  with  alcohol,  and  finally  with  a  1  :  1000  solution  of 
bichloride  of  mercury.  This  is  especially  important  in  cases  of  acute 
pelvic  suppuration,  in  which  thorough  scrubbing  before  ansesthesia  is 
not  tolerated.  The  patient's  clothing  should  be  of  light  flannel — 
undervest,  drawers,  woollen  stockings,  and  night-gown. 

It  is  furthermore  important,  before  beginning  a  grave  operation, 
that  the  various  organs  of  elimination  be  sufficiently  active,  so  that 
the  danger  of  auto-intoxication  from  the  retention  of  waste-products 
may  be  reduced  to  the  minimum.  The  demand  made  upon  the  patient 
by  the  operation  itself  reduces  the  eliminating  capacity  of  these  organs, 
sometimes  to  the  point  of  danger ;  hence  the  imperative  necessity  of 
lightenino;  the  burden.  Careful  examination  of  the  kidnevs  and  heart 
may  lead  to  essential  preparatory  treatment  of  these  organs. 

The  Incision. — To  open  the  abdomen  only  a  few  instruments  are 
required  ;  in  fact,  it  may  be  laid  down  as  a  general  proposition  that 
the  most  skilful  surgeons  operate  w^ith  the  fewest  instruments.  A 
scalpel,  a  few  strong  haemostatic  forceps,  long  and  short,  and  a  pair 
of  strong  straight-bladed  scissors  are  quite  sufficient.  Twelve  short 
and  six  long  haemostatic  forceps  will  suffice  for  any  operation.  Sir 
Spencer  Wells  and  others  have  reported  cases  in  which,  after  the 
operation,  haemostatic  forceps  were  found  post  mortem  in  the  peri- 
toneal cavity.  In  order  to  avoid  tliis,  one  should  operate  always  with 
the  same  number  of  forceps,  or  at  least  carefully  count  and  record 
the  number  before  the  operation  is  begun,  and  before  closure  of  the 
wound.  Unless  the  operator  is  certain  of  his  assistant,  he  will  do. 
well  to  count  them  himself.  The  incision  for  gynecological  explora- 
tion or  operation  is  usually  in  the  median  line  near  the  pubes. 

Exploration. — Every  abdominal  section  should  begin  as  an  explora- 
tory incision,  which  at  first  should  be  made  long  enough  only  to 
admit  the  index  finger  for  examination.  If  it  is  necessary  to  intro- 
duce the  hand,  the  incision  may  be  extended  in  either  direction.  The 
operator  now  decides  whether  he  will  close  the  wound  after  the  simple 
diagnostic  exploration  or  proceed  to  a  complete  operation.  Mr.  Tait, 
in  urging  the  exploratory  incision  as  the  first  step  of  an  abdominal 
operation,  once  wisely  said  :  "  It  is  always  easy  to  turn  an  exploratory 
ineidon  into  an  operation,  hut  often  quite  impossible  to  turn  an  incom- 
plete operation  into  an  exploratory  incision^' 

The  Median  Incision  through  the  Linea  Alba  does  not  expose  nor 
wound  the  recti  muscles.     If,  however,  the  linea  alba  has  been  dis- 


MAJOR   OPERATIONS. 


123 


placed  by  a  tumor  or  by  other  causes  and  is  not  readily  found,  one 
may  properly  ignore  it,  cut  directly  through  the  upper  fascial  sheath, 
separate  the  fibres  of  the  muscle  longitudinally,  and  then  divide  the 
structures  beneath  until  the  cavity  is  reached.  When  cutting  down 
upon  a  tumor,  one  often  reaches  the  linea  alba  with  the  first  stroke  of 
the  scalpel,  and  the  subperitoneal  fat  with  the  second.  The  fat  is 
then  separated  by  the  finger  and  handle  of  the  scalpel,  and  the  peri- 
toneal membrane  exposed.  Bleeding  points  usually  are  secured  by 
})ressure-forceps ;  ligatures  seldom  are  required.  The  peritoneum  is 
then  superficially  caught  by  two  small  pressure-forceps.  The  oper- 
ator's left  hand  retains  one,  and  that  of  the  assistant  the  other.  The 
peritoneum  is  usually  so  translucent  that  the  viscera  just  beneath  can 
be  seen  as  it  glides  over  them  ;  it  is  now  lifted  from  the  viscera  by 
the  pressure-forceps,  and  by  a  single  stroke  of  the  scalpel  divided 


Figure  54. 


Abdominal  incision :  lower  hand  holding  knife  correctly ;  upper  hand  holding 

incorrectly. 


knife 


between  them.  The  grooved  director  formerly  in  use  is  rather  a 
hindrance  than  a  help.  In  grasping  the  peritoneum  in  the  two  for- 
ceps for  incision,  one  should  be  careful  not  to  include  a  bit  of  intes- 
tinal wall.  The  writer  once  in  this  way  opened  the  intestine ;  im- 
mediate suture,  however,  resulted  in  prompt  union,  and  no  permanent 
harm  was  done.  Sometimes  the  intestine  is  adherent  to  the  parietal 
peritoneum  and  is  very  liable  to  be  cut  unless  the  incision  is  made 
slowly  and  with  great  care.  Sometimes  one  may  avoid  cutting 
through  the  bladder-wall  by  recognizing  in  time  its  greater  vascu- 
Jarity  and  the  numerous  little  bleeding  points.  If  the  intestines  or 
bladder  are  adherent  and  unrecognizable,  this  fact  will  be  apparent 
by  the  failure  of  the  operator  to  see  the  viscera  through  the  trans- 
lucent peritoneum,  or  by  the  fact  that  the  peritoneum  does  not,  as  in 
an  ordinary  case,  glide  over  them.  It  is  then  better  to  prolong  the 
incision  upward  or  downward  and  enter  the  abdomen  above  or  below. 


124  GENERAL  PRINCIPLES. 

The  adherent  viscera  may  then  be  detached  and  the  incision  com- 
pleted to  its  original  point.  Deliberation,  care,  and  judgment  will 
enable  the  beginner  usually  to  find  his  way  safely  to  the  abdominal 
cavity. 

The  cavity  being  open,  the  incision  may  be  lengthened  as  desired 
by  the  scissors  on  the  inserted  index-finger  as  a  guide.  The  length 
of  the  incision  will  vary  with  the  requirements  of  the  case  and  the 
dexterity  of  the  operator ;  other  things  being  ecj[ual,  the  shorter  the 
incision  the  less  the  danger.  Sufficient  room,  however,  should  be 
given  for  effective  work.  The  added  risk  of  a  longer  incision  by 
comparison  with  the  added  safety  of  an  unimpeded  operation  is  insig- 
nificant. The  pressure-forceps  may  now  be  removed  from  the  bleed- 
ing-points ;  if  at  any  point  the  bleeding  continues,  it  may  be  controlled 
by  torsion  or  by  fiue  catgut  ligature. 

Before  invading  the  abdominal  cavity  for  purposes  of  examination 
or  operation,  one  should  seize  the  margins  of  the  peritoneum  by  two 
or  three  forceps  on  either  side,  and  draw  it  out  through  the  wound 
toward  its  cutaneous  edges  so  as  to  make  it  cover  the  cut  surfaces. 
The  wound  thereby  is  protected  and  the  peritoneum  is  in  no  danger 
of  being  stripped  off  from  its  adjacent  tissues  as  it  might  otherwise 
be  during  the  subsequent  manipulations. 

Adhesions. — The  conditions  which  give  rise  to  adhesions  usually 
also  cause  more  or  less  thickening  of  the  peritoneum.  Sometimes  the 
parietal  peritoneum  is  so  thick  as  to  be  unrecognizable.  The  operator 
may  be  uncertain  whether  he  has  cut  through  the  peritoneum,  and  this 
uncertainty  may  be  increased  by  the  presence  of  adherent  intestine. 
Large  areas  of  peritoneum  have  been  detached  from  the  adjacent 
abdominal  wall  under  the  impression  that  the  peritoneum  had  been 
divided,  and  that  intraperitoneal  adhesions  were  being  separated. 
Experience  and  sense  are  the  only  guides.  There  are  no  safe  rules. 
Adhesions  usually  are  separated  by  means  of  the  finger,  the  hand,  or 
the  sponge.  If  great  care  is  not  used  in  separating  intestinal  adhe- 
sions, one  or  more  coats  of  the  bowel  wall  may  be  stripped  off  with 
the  adherent  tissues ;  this  might  result  in  sloughing  and  a  conse- 
quent fecal  fistula.  Such  traumatism  should  be  repaired  promptly 
by  drawing  together  the  peritoneal  margins  with  fine  chromic  catgut 
or  silk  sutures.  The  sponge,  as  used  by  the  late  Thomas  Keith,  is  a 
most  useful  means  of  separating  intestinal  or  omental  adhesions.  By 
firm  and  gentle  sponge  pressure  against  the  adherent  bowel  at  the 
point  of  attachment,  one  literally  may  sponge  it  away  from  the  tumor. 
It  is  surprising  to  note  the  facility  with  which  rather  firm  adhesions 
may  thus  be  broken.  In  breaking  the  adhesions  in  this  way  the  sur- 
geon avoids  stripping  off  one  or  more  coats  of  the  bowel.  On  the 
contrary,  the  peritoneal  covering  of  the  tumor  is  apt  to  remain  on 
the  bowel.  The  sponge  method  is  more  gentle,  more  effective,  and 
less  productive  of  shock  than  the  usual  method  of  tearing  with  the 
finger.     Adhesions  too  strong  for  the  sponge  or  finger  have  to  be  cut. 

Intraperitoneal  Haemostasis. — Hemorrhage  during  an  operation 
is  treated  on  general  surgical  principles  by  forcipressure,  ligature,  tor- 
sion, sponge-pressure,  or  styptics. 


MAJOR   OPERATIONS. 

Figure  55. 


125 


Abdominal  incision,  cutting  through  peritoneum.  Peritoneum  held  up  awav  from  abdom- 
inal viKcera  by  pressure-forceps.  Forceps  on  left  held  by  left  hand  of  assistant ;  forceps  on 
right  held  by  left  hand  of  operator. 


Figure  56. 


Enlarging  abdominal  incision.    Forceps  shown  in  Figure  5.5  are  lying  one  on  either  side  of 
wound  with  everted  margins  of  peritoneum  in  their  grasp. 


126 


GENERAL  PRINCIPLES. 


Figure  57. 


Pressure-forceps  placed  on  small  bleeding  points  as  the  operation 
proceeds,  and  left  there  a  few  minutes,  usually  will  suffice.  If  the 
hemorrhage  continues,  each  point  may  be  secured  by  torsion  or  by  a 
fine  catgut  ligature ;  or  several  points,  by  a  basting  process,  may  be 
included  in  a  ligature.  Troublesome  oozing,  deep  in  the  pelvic  wall, 
often  subsides  on  long-continued  sponge-pressure.     The  sponge  should 

be  wrung  out  in  very  hot  water,  and  very 
firmly  packed  against  the  bleeding  sur- 
face, and  left  there  for  several  minutes. 
Iron,  tannin,  and  alum,  since  they  are 
apt  to  leave  masses  of  coagulated  blood 
which  may  decompose  in  the  pelvis,  are 
objectionable.  A  sterilized  10  per  cent, 
solution  of  antipyrin  applied  with  the 
sponge  is  a  safe  and  often  effective 
styptic. 

Catgut  versus  Silk  for  Ligatures. — 
Hseraostasis  is  secured  best  by  catgut — 
see  Sterilization  of  Catgut,  Chapter  II. 
Catgut  is  preferable  to  silk  because  in 
case  of  localized  infection  around  the  liga- 
ture the  non-absorbable  silk  remains  as 
a  foreign  body  and  is  apt  to  perpetuate 
a  suppurative  process.  This  process,  if 
the  patient  survives,  may  form  a  sinus 
leading  from  the  ligature  to  the  external 
surface,  usually  through  some  point  in 
the  abdominal  wound.  Such  a  sinus  may 
continue  to  suppurate  for  weeks,  months, 
or  years,  until  the  ligature  is  cast  out  or 
manually  removed.  Catgut  sutures  and 
ligatures  disappear  by  absorption  in  a 
few  days  or  weeks,  and  give  no  further 
trouble ;  if  of  good  quality  and  properly 
disinfected,  they  are  perfectly  reliable  and 
safe. 

Closure  of  the  Wound.— The  ordi- 
nary method  by  through-and-through 
interrupted  sutures,  including  the  entire 
thickness  of  the  abdominal  wall,  and 
tying  upon  the  skin,  should  be  abandoned,  and  the  method  of  buried 
chromic  catgut  suture  should  be  substituted. 

The  Buried  Catgut  Suture  Throughout.^ — Number  2  catgut  suf- 
ficiently chromicized  to  resist  absorption  for  six  weeks,  should  be  used. 
The  technique  is  as  follows  :  In  order  to  give  broader  surfaces  for 
union,  and  consequently  greater  strength,  the  incision  is  made  into  the 
sheath  of  the  rectus  muscle  on  that  side  on  which  the  muscle  was 
not  exposed  by  the  abdominal  incision.     If,  perchance,  the  abdominal 


Facial  sheaths  of  rectus  muscle  on 
one  side,  being  split  by  scissors. 


1  Modified  from  George  M.  Edebohls.    American  Gynecological  and  Obstetrical  Journal, 
May,  1896,  consulted. 


Figure  58. 


Figure  59. 


FASCIA 
PERITONEUM 
MUSCLE L 


SUBCUTANEOUSi 


Figure  58.— Showing  deep  tier  of  buried  running  catgut  suture,  which  unites  the  peri- 
toneum. The  suture  may  also  embrace  the  posterior  fascia  and  muscle.  Observe  that  the 
suture  was  introduced  at  A  and  is  there  being  held  in  place  by  means  of  forceps ;  it  first  closes 
peritoneum  from  the  lower  to  the  upper  end  of  the  incision;  it  then  returns  to  the  lower  end, 
closing  the  anterior  fascia,  as  shown  in  Figures  59  and  60,  and  finally  emerges  and  is  tied  at 
point  of  original  entrance — point  A. 

Figure  59. — Fascial  margins  of  wound  closed  by  second  tier  of  buried  running  suture.  The 
recti  muscles  are  now  being  covered  in  by  the  united  fascia. 


Figure  60. 


Figure  61. 


-FASCIA 
-SKIN 


Figure  60.— Union  of  fascial  margins  complete ;  suture  is  being  passed  out  by  needle  to 
point  o-f  entrance  A  preparatory  to  tying.    Suture  is  shown  as  tied  at  A  in  figure  61. 

Figure  61.— The  running  suture,"  which  has  closed  peritoneum,  recti  muscles,  and  fascia  in 
two  tiers  has  been  tied  at  point  of  entrance  and  exit  A.  A  final  suture  first  tied  at  lower  end 
of  wound  is  being  deeply  introduced  to  close  subcutaneous  fat  and  skin,  observe  that  there  are 
no  buried  knots  to  cause  suppuration  and  that  the  deep,  wide  external  suture  closes  the  subcu- 
taneous fat  securely  and  prevents  dead  spaces.  Moreover,  its  relations  with  the  margins  of  the 
wound  are  so  remote  that  it  causes  little  irritation.  Above  all,  it  should  not  be  tightly  drawn — 
just  tightly  enough  to  hold  the  cut  margins  in  apposition  ;  this  suture  should  be  iodized  gut. 

127 


128  GENERAL  PRINCIPLES. 

incision  was  made  directly  through  the  linea  alba,  without  exposing  a 
rectus  muscle,  the  sheath  is  deliberately  to  be  divided  on  either  side 
with  the  scissors,  as  shown  in  Figure  57.  This  gives  double  fascial 
edges  and  broad  muscular  surfaces  for  union.  The  purpose  of  the 
buried  suture  is  to  approximate  the  muscular  and  fascial  layers  of  the 
wound,  so  as  to  insure  apposition  of  homologous  parts,  and  to  retain 
them  in  approximation  long  enough  to  secure  firm  union. 

The  running  suture  is  preferable  to  the  interrupted,  first,  because 
it  brings  corresponding  structures  more  accurately  and  more  quickly 
together  ;  second,  because,  in  the  method  described,  it  gives  no  buried 
knots.  The  second  advantage  is  considerable,  for  the  bulky  catgut 
knot  tends  to  cause  suppuration  or  failure  of  union. 

Closure  of  the  abdominal  wound  by  buried  catgut  sutures  is  made 
as  follows  : 

The  needle  is  introduced  at  the  lower  extremity  of  the  wound  on 
the  right  side  (A,  Figure  58),  and  at  the  first  thrust  is  carried  through 
skin,  fat,  anterior  fascia,  muscle,  and  peritoneum.  The  suture  then  is 
continued  as  a  running  suture  the  length  of  the  wound,  and  unites  the 
peritoneum.  The  posterior  fascia  and  muscle  may  be  united  by  this 
suture  at  the  same  time  with  the  peritoneum.  The  suture  then  is 
carried  back  to  the  starting-point,  whi^^ping  together  the  outer  frag- 
ments of  the  divided  anterior  fascia,  thus  bringing  the  recti  muscles 
firmly  together.  It  finally  emerges  at  the  point  of  entrance,  A,  where 
it  was  introduced  first,  and  is  tied.     Figures  60  and  61. 

In  connection  with  the  subject  of  suture  for  abdominal  incision  the 
reader  is  referred  to  the  Surgical  Treatment  of  Enteroptosis  and  Um- 
bilical Hernia  at  the  end  of  Chapter  XLV. 

The  splitting  of  the  sheaths  of  the  recti  muscles  is  essential  in 
cases  of  relaxed  abdominal  walls,  especially  when  there  are  enterop- 
tosis and  pendulous  abdomen ;  this  method  insures  a  good  result  so 
far  as  the  correction  of  the  side-to-side  relaxation  is  concerned,  but 
does  not  always  overcome  the  longitudinal  relaxation.  Figure  62 
shows  a  method  by  which  the  upper  end  of  the  wound  is  closed  in  a 
line  at  right  angles  to  the  incision  so  as  to  hold  up  the  relaxed  pendu- 
lous abdomen.  The  transverse  part  of  the  closure  may  be  at  the 
upper  or  lower  end  or  anywhere  in  the  continuity  of  the  wound  or 
both  at  the  upper  and  lower  ends.  An  ordinary  continuous  chromic 
or  iodized  catgut  suture  is  sufficient.  For  the  cutaneous  part  of  the 
wound  Claudius'  iodized  gut  is  preferred. 

Stitch-abscesses  are  very  liable  to  occur  unless  the  following  pre- 
cautions are  observed : 

1.  The  abdomen  should  be  opened  with  a  sharp  scalpel,  which  will 
make  a  clean  cut,  not  a  ragged,  uneven  incision. 

2.  Great  care  should  be  used  during  the  operation  not  to  bruise 
or  tear  the  wounded  surfaces. 

3.  All  bleeding  should  be  arrested  before  closure  of  the  wound. 

4.  Absolute  asepsis  should  be  secured  in  hands,  instruments, 
sponges,  sutures,  and,  above  all,  in  the  field  of  incision.  See  Chap- 
ter II. 


MAJOR   OPERATIONS. 


129 


5.  The  sutures  should  not  be  drawn  so  tightly  as  to  strangulate 
the  parts. 

6.  Buried  knots  should  be  avoided. 

Should  suppuration  in  the  wound  or  along  the  sutures  occur,  the 
sutures,  if  of  the  through-and-through  variety  and  tied  on  the  skin, 
should  be  removed  at  once.  The  buried  suture  must  be  left  in  place 
until  it  is  absorbed.     A  dressing,  wet  with  70  per  cent,  alcohol,  should 

Figure  62. 


In  cases  of  enteroptosis  and  pendulous  abdomen  it  may  be  necessary  not  only  to  split  the 
sheaths  of  the  recti  muscles,  but  also  to  remove  a  strip  of  skin  and  subcutaneous  fat  on  either 
side  of  the  wound  in  order  to  take  up  the  lateral  slack  m  the  abdominal  wall.  Not  infrequently 
there  will  still  remain  considerable  longitudinal  slack,  which  should  be  disposed  of  by  uniting 
some  portion  of  the  wound  in  a  direction  at  right  angles  to  the  line  of  incision,  as  follows: 

A.  The  peritoneal  and  fascial  margins  of  the  wound  have  been  closed  completely.  The 
cutaneous  margins  of  the  lower  two-thirds  of  the  wound  have  been  closed  in  the  usual  manner. 
The  upper  third  is  being  held  slightly  apart  by  two  tenacula. 

B.  The  upper  part  of  the  wound  is  being  drawn  widely  apart  by  two  tenacula  so  that  it 
may  be  closed  in  a  direction  running  at  right  angles  to  the  line  of  incision.  The  dotted  lines 
indicate  that  part  of  the  skin  and  subcutaneous  fat  to  be  removed  so  that  the  wound  wheu 
closed  may  have  a  level  surface  all  around  it  free  from  folds. 

C.  The  closure  of  the  wound  is  being  completed  by  the  introduction  of  the  last  stitch.  In 
this  Figure  the  suture  is  not  subcutaneous  but  over-and-over,  although  the  subcutaneous 
suture  would  be  permissible.  The  over-and-over  stitch  is  shown  here  in  order  to  demon- 
strate it. 


be  maintained  continuously.  Free  drainage  by  incision  should  be 
established  if  necessary  to  drain  out  any  considerable  accumulations 
of  pus.  Immobilization  of  the  abdominal  walls  by  a  firm  bandage 
will  tend  to  prevent  separation  of  the  suppurating  wound. 

Sponges. — In  nearly  every  extensive  abdominal  section  numerous 
sponges,   preferably  gauze   sponges,  are  packed   into   the  abdominal 
cavity,  not  only  to  absorb  blood  and  other  fluid,  but  to  control  hemor- 
9 


130 


GENERAL  PRINCIPLES. 


rhage  by  pressure,  and  to  hold  the  intestine  and  other  viscera  out  of 
the  way  of  the  operator. 

How  to  Avoid  the  Leaving  of  Sponges  in  the  Abdomen. — It  is  quite 
impossible  during  the  progress  of  an  abdominal  section  for  the  oper- 
ator to  keep  track  of  the  exact  number  of  sponges  which  may  be  inside 
of  the  abdomen ;  hence  numerous  humiliating,  not  to  say  fatal,  results 
of  closure  of  the  wound  and  completion  of  the  operation  with  one  or 
more  sponges  remaining  in  the  peritoneal  cavity.  The  not  infre- 
quent occurrence  of  this  deplorable  accident,  even  at  the  hands 
of  careful  men,  is  the  writer's  excuse  for  introducing  two  personal 
experiences ;  verily,  how  much  experience  one  may  get  from  a  single 
case  ! 

The  first  case  was  one  of  extensive  suppuration  of  the  uterine 
appendages  with  nearly  universal  old,  firm  adhesions  throughout  the 
pelvis,  and  with  the  uterus  enlarged  by  chronic  endometritis  and 
metritis  to  about  four  times  its  natural  size.     All  the  diseased  organs 


Figure  63. 


Abdominal  wound  has  been  closed  by  cutaneous  and  buried  sutures.  In  some  cases  the 
skin-margins  do  not  fall  closely  enough  together ;  it  is  then  necessary  to  unite  them  by  means 
of  a  continuous  or  interrupted  suture  with  a  very  fine  long  needle,  with  sharp  point,  threaded 
with  fine  catgut. 

were  removed  by  abdominal  and  vaginal  section.  The  operation, 
especially  the  hysterectomy,  was  exceptionally  difficult  and  tedious. 
The  broad  ligaments  were  so  short  and  thick  as  to  be  inaccessible  for 
the  ligature,  and  almost  for  the  clamps.  Each  ligament  was  so  thick 
that  through  the  vagina  it  had  to  be  clamped  in  three  parts.  The 
patient  was  put  to  bed  apparently  nearer  dead  than  alive.  The 
writer's  usual  precautions  had  been  taken  to  prevent  closing  the 
wound  with  a  sponge  inside.  The  sponges  had  been  brought  to  the 
operation  in  sterilized  packages  each  containing  eight,  so  that  the 
number  must  have  been  eight  or  some  multiple  of  eight.  Only  large, 
flat  gauze   sponges   were   used.     The   operation  was  begun  with  the 


MAJOR    OPERATIONS.  131 

eight  sponges  of  one  package,  which  were  counted.  Two  additional 
packages  of  eight  each  were  required  in  the  course  of  the  operation, 
all  of  which  were  supposed  to  have  been  counted  accurately  by  the 
nurse  in  charge  of  them.  Just  before  the  abdominal  sutures  were 
introduced  the  nurse  was  directed  to  count  the  sponges.  She  reported 
them  "all  out."  After  the  introduction  of  the  sutures,  and  before 
they  were  tied,  she  was  told  to  count  them  again,  and  this  count  also 
made  the  number  twenty -four  and  "  all  out."  With  the  evidence  of 
a  double  count,  that  there  could  be  no  sponge  in  the  abdomen,  the 
wound  was  closed. 

Three  hours  later  the  nurse  reported  that  one  of  the  gauze  sponges 
used  in  the  abdomen  could  not  be  found.  After  consultation  with 
two  colleagues  it  was  decided  to  assume  for  the  time  that  the  missing 
sponge  had  been  lost  outside  the  abdomen,  and  that  consequently  the 
peritoneal  cavity  was  clear. 

Convalescence  was  uninterrupted  till  the  tenth  day,  when  the 
stitches  were  removed.  At  this  time  there  was  noticed  a  semi-reso- 
nant mass  of  irregular  ovoid  shape,  as  large  as  a  medium-size  orange, 
in  the  region  of  the  right  kidney ;  it  gave  to  the  palpating  hand  the 
sensation  of  a  mass  of  gauze  mingled  with  adjierent  intestine.  Two 
colleagues  agreed  that  it  would  be  wise  to  wait  for  developments.  Six- 
teen hours  later,  at  11  p.m.,  the  mass  had  increased  in  size,  become 
painful,  the  pulse  had  risen  from  100  to  120,  and  the  temperature 
from  99°  to  101°  F.  There  was  slightly  increased  distention,  accom- 
panied by  a  tendency  to  pronounced  nausea.  After  a  hasty  consulta- 
tion, the  family  being  informed  of  our  suspicions  and  fears,  chloro- 
form was  given  and  the  abdomen  opened  directly  over  the  mass. 
The  incision  was  made  without  the  usual  assistants,  at  midnight,  and 
revealed,  not  a  sponge,  but  a  much  enlarged  kidney  surrounded  and 
covered  by  firmly  adherent  intestine  looped  and  matted  together  in 
an  irregular  mass.  In  working  through  the  thickened,  unrecognizable, 
adherent  parietal  peritoneum,  and  between  the  layers  of  visceral  perito- 
neum and  the  adherent  intestine,  also  thickened  and  difficult  to 
recognize,  the  intestine  was  opened  accidentally.  The  opening  im- 
mediately was  repaired  with  interrupted  Lembert  sutures,  and  the 
abdominal  wound  closed  without  drain. 

Three  days  later  the  contents  of  the  small  intestine,  probably  the 
upper  part  of  the  ileum,  came  through  the  abdominal  wound,  and  an 
intestinal  fistula  thereby  was  demonstrated.  During  the  following 
five  weeks  no  feces  passed  by  the  anus :  all  bowel  evacuations  came 
through  the  fistula.  The  opening  was  so  high  in  the  bowel  that  nutri- 
tion seriously  was  impaired  and  emaciation  began.  The  fear  of  a  for- 
midable operation  to  restore  the  integrity  of  the  bowel  increased  day 
by  day.  Finally,  to  the  writer's  unspeakable  relief,  in  the  sixth  week 
fecal  matter  appeared  at  the  anus.  The  fistula  began  to  contract,  and 
in  a  few  days  was  closed  completely.  The  kidney  enlargement  entirely 
subsided,  and  repeated  urinalysis  showed  no  evidence  of  functional 
impairment. 

The  prolonged  anxiety  and  distress  of  such  a  case  are  beyond 
description.     They  are,  both  for  the  surgeon  and  for  the  patient^  9, 


132  GENERAL  PRINCIPLES. 

life-shorteniug  experience.  The  burden  of  this  case  was  lightened, 
first,  by  the  ultimate  recovery  of  the  patient ;  second,  by  the  complete 
relief  which  she  has  experienced  since  from  a  distressing  intestinal 
catarrh  which  had  made  her  a  semi-invalid  for  fifteen  years.  This 
relief  is  attributed  to  the  continuous  rest  to  which  that  portion  of  the 
bowel  below  the  injury  was  subject  while  the  fistula  was  open. 

The  second  case  was  one  of  intraligamentous  ovarian  cyst  on  each 
side,  with  double  sactosalpinx  serosa  and  universal  adhesions.  The 
sponges  were  counted  carefully  before  the  incision  was  made.  Before 
the  wound  was  closed,  the  nurse  again  counted  them  and  reported  one 
missing.  After  a  search  of  fifteen  minutes  among  the  abdominal 
viscera,  the  nurse  in  the  meantime  looking  for  the  sponge  outside, 
it  could  not  be  found.  In  the  hope  of  finding  the  sponge,  the  inci- 
sion, previously  short,  was  extended  to  the  navel,  preparatory  to  turn- 
ing out  the  intestines,  when  the  nurse  found  the  sponge  outside ;  it 
had  carelessly  been  misplaced  in  a  jar  and  overlooked.  The  patient 
fortunately  recovered. 

These  two  cases  illustrate  the  degree  to  which  a  surgeon,  with  all 
the  responsibility,  may  be  powerless  to  protect  his  patient  against  the 
inefficiency  or  carelessness  of  an  assistant  whose  shortcomings,  per- 
chance, he  may  be  unable  to  discover  until  it  is  too  late. 

The  precautions  which  may  be  taken  in  order,  so  far  as  possible, 
to  guard  against  accidentally  leaving  a  sponge  in  the  abdominal  cavity 
are  as  follows  : 

1.  All  sponges  should  be  so  large  as  not  easily  to  be  overlooked  by 
the  operator.  If  sea-sponges  are  used,  let  them  all  be  the  largest  flat 
sponges,  and  of  as  nearly  uniform  size  as  possible.  Gauze  sponges  are, 
however,  preferable.  They  should  be  made  of  good  absorbent  gauze 
in  four  thicknesses,  and  should  be  of  uniform  size,  at  least  six  inches 
wide  by  twelve  to  sixteen  inches  long.  All  sponging  can  be  done 
with  large  as  well  as  with  small  sponges.  Let  the  smaller  ones,  then, 
be  discarded.     They  serve  no  necessary  purpose. 

2.  All  sponges  designed  for  abdominal  section  should  be  kept  in 
packages  of  eight  each.  This  number  will  suifice  for  the  ordinary 
operation.  If  more  are  needed,  additional  packages  may  be  opened. 
As  soon  as  a  package  is  opened,  the  sponges  should  accurately  be 
recounted  and  recorded.  Invariably  this  precaution  will  fix  the 
number  for  any  operation  at  eight  or  a  multiple  of  eight. 

3.  Toward  the  close  of  the  operation  the  sponges  again  should  be 
counted.  Experience  has  shown  that  under  the  demoralizing  influence 
of  hurry  and  excitement  which  often  attend  the  close  of  a  desperate 
operation,  the  nurse  in  charge  of  the  sponges  is  liable  to  blunder  in  the 
count.  It  is  well,  therefore,  that  the  count  be  repeated  two  or  three 
times,  and,  if  possible,  by  different  individuals. 

Another  practical  means  of  avoiding  the  loss  of  sponges  that  may 
have  been  packed  into  the  abdomen  is  to  have  them  fastened  in  groups 
of  two  by  narrow  strips  of  tape.  Figure  64,  B,  the  strips  being  about 
twelve  inches  long.  One  might  readily  overlook  one  sponge  in  the 
cavity,  but  he  could  hardly  overlook  two.  Moreover,  sponges  fastened 
together  in  this  way  are  counted  easily  when  removed.     The  plan  of 


MAJOR   OPERATIONS. 


133 


attaching  a  tape  to  each  sponge  and  letting  the  end  remain  outside  is 
objectionable,  for  many  protruding  strips  of  tape  would  be  in  the  way 
of  the  operator,  and,  what  is  worse,  one  or  more  strips,  even  though 
held  by  forceps,  might  accidentally  slip  in  and  be  lost.  The  long 
sponge  roll  of  Mayo,  Figure  64,  C,  is  most  serviceable  for  packing 
intestine  out  of  the  way  of  the  operator. 

Figure  64. 


A,  gauze  sponge  on  long  forceps  for  deep  sponging  in  the  pelvic  or  abdominal  cavity; 
B,  gauze  sponge  fastened  tugeiher  with  lape  as  a  precaution  against  leaving  it  in  the  peri- 
toneal cavity ;  C.  long  sponge  roll  for  packing  intestines  out  of  operator's  way. 

The  operator,  whose  every  energy  is  employed  in  the  effort  tc 
shorten  the  time  of  operation,  cannot  stop  for  sponge-counting ;  yet 
only  a  surgeon  can  appreciate  the  satisfaction  which  lies  in  the  abso- 
lute knowledge  that  every  sponge  is  out.  The  writer,  therefore,  now 
uses  a  simple  device  by  which  the  number  of  sponges  may  at  a  glance 


134 


GENERAL  PRINCIPLES. 


be  apparent  to  any  one.  It  is  tliis :  At  the  time  of  closing  the  wound 
the  sponges  are  arranged  in  uniform  rows  on  the  floor.  The  subject 
is  so  urgent  that,  even  at  the  risk  of  seeming  triviality,  the  accom- 
panying illustration  is  introduced. 

There  are  manifest  advantages  in  not  having  the  sponges  washed 
during  the  operation.      A  sufficient  number  should  be  provided,  so 

Figure  65. 


Sponges  arranged  in  rows  to  facilitate  ceunting  at  the  end  of  an  operation. 

that  they  may  always  be  used  dry,  and  discarded  as  soon  as  they  are 
soiled.  In  this  way  the  operator  may  dispense  with  one  assistant,  the 
sponge- washer,  and  so  limit  the  danger  of  infection. 

Dressings  and  Bandages. — The  usual  combination  aseptic 
dressing  of  gauze  and  wood-wool  or  cotton,  secured  by  strips  of  adhe- 
sive plaster  and  a  firm  abdominal  bandage,  will  suffice.  The  nurse 
should  be  cautioned  to  use  care  lest  the  dressing  and  bandage  slip  up 
and  expose  the  lower  end  of  the  wound.  If  a  vulvar  dressing  also  is 
used,  it  should  be  kept  separate  from  the  abdominal  dressing,  for 
otherwise  fluids  may  pass  by  capillary  attraction  from  one  to  the  other ; 
this  may  explain  the  fact  that  stitch  abscesses  often  begin  at  the 
lower  end  of  the  wound.  It  is  well  to  use  two  abdominal  bandages, 
one  to  reach  from  the  hips  to  the  umbilicus,  or,  if  necessary,  higher, 
and  the  other  to  lap  over  the  lower  part  of  this  and  reach  to  the  mid- 
dle of  the  thighs.  The  lower  bandage  keeps  the  dressing  from  slip- 
ping upward.  It  may  be  loosened  for  movement  of  bowels  or 
urination. 

Dusting  Powders  for  the  Wound. — The  author  has  used  dusting 
powders  extensively  and  with  good  results,  but  recent  experience  has 


31  A  JOE   OPERATIONS. 

Figure  66. 


135 


B 


f^' 


'>< 


A,  Two  layers  of  gauze  with  cotton  between  lying  on  the  closed  wound  ;  B.  gauze  and  cot- 
ton dressing  being  secured  in  place  by  means  of  a  wad  of  cotton  held  in  the  grasp  of  a  forceps 
and  saturated  with  collodion  ;  C,  gauze  and  cotton  dressing  further  held  in  place  by  means  of 
perforated  adhesive  plaster.  Observe  this  plaster  in  three  pieces,  the  two  lower  pieces  being 
placed  parallel  to  Poupart's  ligament  so  that  on  retraction  of  the  thighs  the  plaster  will  not  be 
lifted  off. 

convinced  hira  that  in  careful  aseptic  surgery  all  dusting  powders  may 
be  dispensed  with  to  advantage. 

In   ordinary   cases   in    which    there   is   little   probahilitv   that   the 


136  GENERAL  PRINCIPLES. 

wound  will  have  to  be  dressed  or  otherwise  disturbed,  it  is  better  to 
apply  the  dressings  and  secure  them  by  perforated  adhesive  plaster, 
as  shown  in  Figure  66.  The  wound  is  covered  first  by  a  single  layer 
of  gauze.  This  gauze  is  made  fast  by  means  of  collodion.  In  order 
not  to  confine  any  possible  secretion  which  may  escape  from  the  wound, 
the  collodion  should  surround,  but  should  not  cover,  the  line  of  union. 
On  this  layer  of  gauze  is  placed  a  layer  of  absorbent  cotton,  and  over 
the  cotton  a  second  layer  of  gauze,  Figure  66,  A  and  B,  which  also  is 
made  fast  by  collodion.  A  few  additional  layers  of  gauze  are  now 
loosely  placed  over  that  part  of  the  dressings  already  described,  and 
the  whole  is  held  in  place  by  perforated  adhesive  plaster,  as  shown  in 
Figure  QQ,  C.  The  advantages  of  holding  the  dressings  in  place  by 
means  of  adhesive  plaster  instead  of  the  usual  abdominal  binder  are 

FKitJRE  67. 


This  Figure  sliows  perforated  plaster  over  the  dressings  of  an  abdominal  wound.  This  is 
the  usual  method  of  application,  but  is  faulty,  because  when  the  thighs  are  retracted  the  plaster 
is  apt  to  be  lifted  from  the  wound.    The  correct  method  is  shown  in  Figure  66. 

as  follows :  1,  the  wound  is  protected  absolutely  against  exposure  by 
the  carelessness  of  nurses,  who  are  prone  to  permit  the  abdominal  bin- 
der to  be  displaced  upward,  and  thereby  to  leave  the  wound  exposed  ; 
2,  the  dressings  of  the  gauze  and  cotton,  secured  by  collodion  and 
covered  by  perforated  plaster,  give  the  patient  much  less  discomfort 
than  the  ordinary  cumbersome  dressings  of  large  quantities  of  gauze, 
cotton,  and  other  absorbent  materials,  which  are  held  in  place  by  the 
conventional  abdominal  binder. 

2.  VAGINAL  SECTION. 

The  vaginal  route  for  opening  into  the  peritoneal  cavity  is  often 
preferable.  The  incision  may  be  made  between  the  uterus  and  rectum 
or  between  the  uterus  and  bladder.     The  technique  of  the  procedure 


MAJOR   OPERATIONS.  137 

varies  within  wide  limits,  and  will  be  described  under  special  oper- 
ations. See  Vaginal  Section  in  the  chapter  on  the  Treatment  of 
Pelvic  Inflammation. 

3.  SACRAL  RESECTION. 

Hysterectomy  and  other  intrapelvic  operations  have  been  performed 
through  an  opening  made  by  resection  of  the  sacrum  after  the  method 
of  Kraske.  The  precise  value  of  the  method  has  not  been  estab- 
lished. 


CHAPTER  VII. 

DRAINAGE  IN  MAJOR  OPERATIONS. 
INFECTIOUS   AND   NON-INFECTIOUS    CASES. 

Two  classes  of  drainage  cases  present  themselves ;  first,  cases 
which,  up  to  the  time  of  operation,  are  free  from  infection ;  second, 
cases  in  which  infection  has  occurred  previous  to  the  operation.  To 
the  first  class  belong  solid  and  cystic  tumors  and  tubal  pregnancies 
which  have  not  become  infected ;  to  the  second  class  belongs  pelvic 
inflammation  in  its  various  forms  and  stages,  such  as  inflammation  of 
the  Fallopian  tube  and  ovary,  including  pelvic  abscess,  pyosalpinx, 
and  infected  tumors. 

In  the  non-infectious  cases  drainage  is  resorted  to  for  the  removal 
of  blood,  serum,  or  other  non-infectious  fluids  such  as  otherwise  might 
accumulate  in  the  peritoneum,  and,  if  left  there,  become  infectious. 
Experiment  and  experience,  however,  have  shown  that  the  non- 
infected  blood  and  serum  which  may  accumulate  in  the  peritoneum 
after  a  clean,  adequate  operation  have  little  or  no  power  for  harm. 
Serum  and  liquid  blood  are  absorbed  rapidly.  Coagulated  blood  may 
be  absorbed,  or  it  may  become  encapsulated  and  gradually  removed 
by  the  action  of  leucocytes ;  or  it  may  become  organized  and  remain 
harmless  for  an  indefinite  period.  Both  blood  and  serum  are  excellent 
culture-media  for  microbes  ;  hence  the  necessity  to  keep  them  non- 
infectious by  aseptic  surgery.  The  peritoneum  has  great  power  to 
resist  infection,  and  is  known  to  take  up  and  dispose  of  large  quanti- 
ties of  infectious  material,  even  without  drainage.  Recent  studies  and 
experience  prove  that  the  drain  is  often  more  potent  as  a  medium  for 
the  introduction  of  sepsis  than  for  the  removal  of  it.  Drainage,  on 
account  of  infection,  therefore,  after  a  clean  operation  in  a  case  not 
hitherto  infected,  is  contraindicated. 

Bacteriological  examinations  of  reproductive  organs  removed  for 
chronic  inflammatory  disease  frequently  show  that  the  pus  is  sterile, 
or,  if  organisms  are  present,  they  may  be  inactive  at  the  time  of  the 
operation.  Formerly  the  escape  of  the  smallest  quantity  of  pus  into 
the  peritoneum  during  an  operation  was  considered  an  imperative 
indication  for  drainage.  Now,  the  escape  of  even  large  quantities  if 
free  from  virulent  or  active  microbes,  does  not  call  for  drainage. 

Comparison  of  Results. — Large  numbers  of  drained  pus-cases 
and  equal  numbers  of  like  cases  not  drained  uniformly  show  a  strong 
preponderance  of  recoveries  in  the  non-drainage  series.  This  pre- 
ponderance is  proof  that  the  drainage  was  useless,  and  that  the  larger 
mortality  in  the  drained  cases  is  attributable  to  infection  introduced 
through  the  drain. 

138 


DRAINAGE  IN  MAJOR   OPERATIONS.  139 

Evil  Results  of  Drainage. — In  addition  to  the  greatly  increased 
danger  already  mentioned  from  the  direct  introduction  of  infection 
through  the  medium  of  the  drain,  the  following  evil  results  of  drain- 
age may  be  mentioned  as  not  infrequent : 

1.  Obstruction  of  the  bowel. 

2.  Fecal  fistula. 

3.  Vesical  complications. 

4.  Hernia. 

5.  Intoxication  by  iodoform  gauze  or  other  medicated  gauze. 

1.  Obstruction  may  occur  from  adhesions  set  up  by  the  irritating 
presence  of  the  drain.  An  adherent  intestine  sharply  kinked  may 
become  suddenly  impermeable,  or  gradually  contracting  bands  may 
shut  off  its  lumen  slowly.  Most  frequently  the  obstruction  is  partial, 
and  gives  rise  to  constipation  and  griping  pains  for  days  or  weeks  after 
the  operation.  In  such  cases,  when  fatal,  the  autopsy  usually  has 
shown  the  intestines  matted  around  the  drainage  cavity  in  an  unrecog- 
nizable mass. 

2.  Fecal  Fistula  is  the  occasional  result  of  necrosis  from  direct 
pressure  of  the  drain  or  from  the  irritating  presence  of  a  gauze  drain 
and  consequent  infection  so  destructive  as  to  produce  necrosis  and 
consequent  fistula.  If  the  bowel  has  been  opened  during  an  opera- 
tion, and  has  been  well  repaired,  drainage  is  unfavorable  to  union  and 
is  contraindicated.  If,  however,  the  intestinal  opening  has  been  made 
d^ep  in  the  pelvis,  or  is  otherwise  so  inaccessible  as  to  prevent  thor- 
ough suturing ;  if,  in  a  word,  union  is  improbable,  drainage  is  indicated 
as  a  means  of  exit  for  fecal  matter. 

The  greatest  care  in  covering  all  raw  surfaces  with  peritoneum  and 
stitching  it  down  with  fine  continuous  catgut  sutures,  is  one  of  the  most 
imperative  measures  for  the  reduction  of  mortality  in  abdominal  sur- 
gery ;  even  the  bad  condition  of  a  patient  and  the  necessity  for  rapid 
operating  will  seldom  be  an  excuse  for  neglect  of  this  precaution. 

3.  Vesical  Complications. — The  territory  to  be  drained  is  usually  in 
close  relation  with  the  bladder.  Infection  around  the  drain,  therefore, 
may  give  rise  to  adhesions  between  the  bladder  and  adjacent  organs, 
or  may  invade  the  bladder ;  in  either  case  vesical  disturbance  more  or 
less  severe  may  arise. 

4.  Hernia  in  drained  cases  is  much  more  common  tlian  usually  is 
supposed.  This  is  because  the  drain  separates  the  fascial  sheaths  of 
the  recti  muscles  and  other  surfaces  which  otherwise  would  unite 
immediately  ;  the  small  breach  thus  made  in  the  wall  increases,  and 
more  or  less  hernia  is  the  result.  Hernia  less  often  results  from 
vaginal  than  from  abdominal  drainage. 

To  Prevent  Infection,  and  thereby  to  avoid  the  necessity  for 
drainage,  is  an  essential  purpose  of  every  abdominal  section.  The 
subject  may  be  summed  up  in  the  pro])osition  that  the  operation  should 
be  performed  in  such  a  way  as  not  to  require  drainage.  This  involves 
the  following  precautions  :, 

1.  Insure  thorough  asepsis  of  hands,  instruments,  and  other  appli- 
ances.    See  Chapter  II.,  on  Antiseptics  and  Asepsis. 

2.  Wherever  the  peritoneum  is  injured  or  sacrificed,  let  the  injured 


140  GENERAL  PRINCIPLES. 

part,  if  possible,  be  covered  by  adjacent  peritoneum.  This  may  require 
numerous  sutures  and  careful  plastic  work. 

3.  Control  hemorrhage,  if  practicable,  even  to  small  oozing  points. 
This,  for  want  of  time  or  for  other  reasons,  may  be  impracticable.  It 
may  then  be  safe  to  leave  small  accumulations  to  be  taken  up  by  the 
peritoneum  rather  than  by  a  drain. 

4.  Avoid  all  unnecessary  injury  of  the  tissues.  All  traumatisms 
favor  sepsis.  Do  the  ojjeration  adequately,  but  with  the  least  possible 
amount  of  operating. 

5.  As  a  most  important  precaution,  let  the  bowels  be  evacuated 
thoroughly  before  beginning  the  operation.  Any  considerable  quan- 
tity of  gas  in  the  bowel  is  a  source  of  danger. 

If  during  the  operation  pus  ruptures  into  the  peritoneal  cavity,  it 
should  be  removed  as  soon  as  possible  by  careful  sponging.  If  the 
pus  is  sterile,  the  sponging  is  sufficient.  If  there  is  reason  to  fear  that 
it  is  septic,  the  peritoneal  cavity  should  be  irrigated  freely  with  a  nor- 
mal salt  solution,  0.6  per  cent.  Clark  advocates  thorough  peritoneal 
irrigation  whenever  any  pus  comes  in  contact  with  the  peritoneum. 
He  says  :  "Por  the  last  three  years  it  has  been  our  custom  not  only 
to  irrigate  the  abdominal  cavity  thoroughly  after  all  operations  where 
pus  or  other  fluids  have  escaped,  but  frequently  also  to  leave  as  much 
as  one  litre  of  salt  solution  in  the  peritoneal  cavity  before  closing  the 
abdominal  wound."  The  writer  cannot  too  strongly  urge  the  retention 
of  as  much  salt  solution  in  the  abdomen  after  irrigation  as  the  ordi- 
nary abdomen  will  hold  ;  an  abdomen  of  very  large  capacity  with 
excessively  lax  walls  would  hold  too  nuich.  The  solution  being  ab- 
sorbed rapidly,  carries  out  septic  matter,  increases  arterial  pressure, 
and  relieves  the  intolerable  thirst  of  which  most  laparotomy  patients 
complain.  Such  a  sense  of  well-being  follows  the  retention  of  consider- 
able quantities  of  salt-water  in  the  abdomen  that  the  use  of  it  as  an 
almost  routine  measure  even  for  the  non-pus  cases  is  permissible. 
Moreover,  the  filling  of  the  abdomen  with  fluid  displaces  the  air  that 
would  otherwise  be  retained  in  the  peritoneal  cavity  after  closure  of 
the  wound. 

The  usual  method  of  flushing  the  cavity  by  means  of  salt  solution 
poured  through  the  wound  into  the  cavity  from  a  pitcher  or  flask  is  in 
may  cases  quite  inadequate,  because  the  cavity  may  be  so  filled  with 
viscera  that  the  solution  thus  introduced  cannot  reach  the  deeper  por- 
tions of  the  abdomen  or  pelvis.  In  order  to  make  the  flushing  effec- 
tive, the  solution  may  be  introduced  through  a  canula  attached  to  a 
rubber  tube,  the  tube  leading  from  a  reservoir  above.  The  end  of 
this  canula  can  be  passed  through  the  wound  and  made  to  transmit 
the  solution  thoroughly  to  all  parts  of  the  peritoneal  cavity.  A  very 
practical  substitute  for  the  canula  is  shown  in  Figure  68.  The  salt 
solution  is  held  in  a  funnel-like  metallic  reservoir,  to  which  is  attached 
a  rubber  tube  at  least  three-fourths  of  an  inch  in  diameter.  At  the 
end  of  this  tube  is  fastened  a  long  straight  pressure-forceps,  as  shown 
in  Figure  68.  By  means  of  this  forceps  the  end  of  the  rubber  tube 
may  be  carried  into  any  part  of  the  peritoneal  cavity,  and  the  solution 
rapidly  and  thoroughly  introduced  in  very  large  quantities.     During 


DRAINAGE  IN  MAJOR   OPERATIONS.  141 

the  process  of  flushing  additional  quantities  of  solution  may  be  poured 
from  pitchers  into  the  metallic  reservoir.  By  this  means  many  gal- 
lons of  solution  may  be  brought  rapidly  in  contact  with  every  part  of 
the  peritoneal  cavity.  In  using  this  apparatus  it  is  essential  that  there 
be  a  free  outlet  through  the  wound,  for  otherwise  the  pressure  exerted 
upon  the  diaphragm  by  the  column  of  water  might  be  dangerous. 

Figure  68. 


Apparatus  for  flushinpr  out  abdominal  cavity,  consisting  of  a  metallic  funnel-like  reservoir 
with  two  handles  to  be  held  above  the  level  of  the  patient.  A  rubber  tube  three-fourths  of  an 
inch  in  diameter  leads  from  the  reservoir.  At  the  end  of  the  tube  may  be  attached  a  canula, 
or  as  shown  in  the  figure  a  forceps,  for  the  purpose  of  carrying  the  solution  to  the  deeper  parts 
of  the  peritoneal  cavity. 

It  is  a  well-known  principle  in  physics  that  a  substance  will 
undergo  dissipation  much  more  rapidly  in  an  attenuated  state  than 
when  it  is  massed.  The  same  principle  may  be  applied  to  the  dis- 
posal of  foreign  matter  in  the  peritoneal  cavity  ;  hence  the  advantage 
of  attenuating  any  infectious  matter  that  may  be  in  the  cavity  with 


142  GENERAL  PRINCIPLES. 

great  dilutions  in  salt  solution  ;  this  advantage  is  increased  by  the  salt^ 
which  has  antiseptic  properties. 

CONTRAINDICATIONS  FOR  PERITONEAL  DRAINAGE. 

Drainage  is  contraindicated  under  the  following  conditions : 

1.  Aseptic  operations  in  which  there  is  no  pus  or  other  source  of 
infection. 

2.  Operations  in  Avhich  there  is  pus,Hbut  in  which  the  sac  contain- 
ing it  is  removed  intact  so  that  no  pus  has  escaped. 

3.  Operations  in  which  pus  has  escaped,  but  where  immediate 
microscopical  examination  of  a  smear  shows  it  to  be  sterile. 

4.  Operations  in  which  a  moderate  quantity  of  infectious  pus  has 
escaped  and  has  been  washed  out  thoroughly  with  large  quantities  of 
normal  salt  solution.  The  question  of  drainage  in  this  class  of 
cases  is  not  fully  settled,  but  the  trend  of  opinion  is  in  favor  of  irri- 
gation and  against  drainage,  for  in  most  cases  the  peritoneum  will  take 
up  and  safely  dispose  of  considerable  infectious  matter. 

INDICATIONS   FOR   PERITONEAL   DRAINAGE. 

Drainage  is  indicated  in  the  following  class  of  cases : 

1.  General  septic  peritonitis. 

2.  The  presence  of  a  localized  pus-producing  surface  which  may 
continue  to  secrete  a  greater  amount  of  septic  matter  than  the  perito- 
neum can  take  up,  and  which  therefore  may  be  a  dangerous  source  of 
infection.  Under  these  conditions  drainage  is  indicated  at  the  tim« 
of  operation.  The  source  of  infection  may  be  an  open  intestine  ;  \  an 
abscess ;  an  adherent  necrotic  irremovable  cyst ;  an  infected  hsemalto- 
cele,  or  an  abundance  of  necrotic  tissue  which  cannot  safely  be 
removed.  If  after  an  operation  infectious  fluid  becomes  walled  off  by 
plastic  effusion,  thereby  forming  an  abscess,  no  time  should  be  lost  in 
opening  and  draining  it. 

3.  Hemorrhage,  for  the  control  of  which  the  ligature,  forcipressure, 
and  hot  sponge  packing  are  inadequate. 

DIFFERENT  FORMS  OF  DRAINAGE. 

Tubular  Drainage  is  usually  through  soft  rubber  or  small  glass 
tubes.  For  drainage  through  the  vagina  rubber  is  preferable  to  glass. 
The  tube  is  especially  useful  as  a  medium  for  drainage  and  for  wash- 
ing out  septic  cavities,  such  as  abscesses  which  have  been  walled  off  by 
plastic  lymph  from  the  general  peritoneum.  The  presence,  however, 
of  a  tube  in  the  peritoneal  cavity  usually  causes  in  a  few  hours  the 
surrounding  organs  to  be  fused  together.  The  space  which  the  tube 
occupied  is  isolated  then  from  the  remainder  of  the  peritoneum,  and 
is  the  only  space  which  it  possibly  can  drain.  For  this  reason  tubular 
drainage  in  the  abdomen  for  the  most  part  has  been  discarded. 

Capillary  Drainage. — The  continuous  strip  of  gauze  has  been 
used  extensively  for  capillary  peritoneal  drainage  through  both  the 
vaginal  and  the  abdominal  wound. 


DRAINAGE  IN  MAJOR   OPERATIONS. 


143 


There  are  two  principal  indications  for  the  use  of  gauze  packing  in 
abdominal  and  pelvic  operations :  1.  Hemorrhage  which  cannot  be 
controlled  practically  in  any  other  way  without  unduly  prolonging  the 
operation ;  the  packing  then  used  is  immediately  a  compress,  but  if 


Figure  69. 


Reid's  rubber  drain,  A,  B,  C,  D.  This  drain  has  two  wings,  C,  which  make  it  self-retaining 
when  placed  in  a  pus-cavity.  The  wings  may  be  held  together  by  forceps,  D,  to  facilitate  intro- 
duction ;  A,  B,  and  C  show  the  steps  in  the  formation  of  the  drain  :  E,  F,  ordinary  double  rub- 
ber drains ;  G,  a  rubber  drain  surrounding  a  roll  of  gauze  for  capillary  drainage ;  H,  ordinary 
glass  drainage-tube  for  abdominal  drainage. 

left  longer  than  is  necessary  tor  haemostatic  purposes  it  becomes  a  capil- 
lary drain.  2.  The  desirability  of  quarantining  the  field  of  operation 
from  the  general  peritoneal  cavity.  The  rapidity  with  which  adhe- 
sions form  around  the  pacldng  is  well  known.  In  a  few  hours  a  septic 
area  may  be  shut  off  from  the  general  peritoneum  by  adhesions  which 
form  around  the  gauze  packing,  and  in  this  way  septic  fluid  is  walled 
off  and  mostly  confined  within  narrow  limits. 


144 


GENERAL  PRINCIPLES. 


The  use  of  gauze  for  packing  should  not  be  confounded  with  the 
use  of  it  as  a  drain.  The  value  of  gauze  for  drainage  as  usually  under- 
stood— that  is,  for  the  removal  by  capillary  attraction  of  any  fluid 

Figure  70. 


The  upper  five  rubber  tubes  show  the  steps  in  the  forriiatiou  of  Reid's  rubber  drain  for 
through-and-throufrh  abdominal  drainap-e.  The  Figure  below  shows  the  drain  in  place  pro- 
jectiuK  upward  through  the  lower  end  of  the  abdominal  wound  and  held  there  by  a  safety-pin. 
The  other  end  of  the  drain  is  projected  downward  from  the  abscess-cavity  through  Douglas' 
pouch  and  the  vagina  to  the  vulva.  Each  end  of  this  drain  is  protected  by  a  gauze  pad.  These 
pads  are  held  in  place  by  an  abdominal  binder  and  a  T-bandage,  and  should  be  changed  suffi- 
ciently often  to  keep  them  dry. 


which  may  form  in  the  peritoneal  cavity — is  overestimated.  The 
peritoneum  often  has  demonstrated  its  ability  to  take  care  of  large 
quantities  ol  secretion.     If,  as  many  assert,  it  be  true  that  the  presence 


DRAINAGE  IN  MAJOR   OPERATIONS. 


145 


of  a  drain  excites  the  secretion  of  large  quantities  of  fluid  whicli 
would  not  otherwise  be  secreted,  it  follows  that  the  drain  is  often 
not  so  necessary  as  the  large  quantities  of  fluid  which  it  carries  oft' 
would  seem  to  indicate.  Clearly  it  would  be  absurd  to  use  a  drain  for 
the  purpose  of  carrying  oft"  secretions  which  it  had  itself  excited. 
Moreover,  the  gauze  packing  often  acts  as  an  obstruction  to  the 
removal  of  fluids,  and  may  therefore  defeat  the  purpose  of  drainage. 
Abdominal  Drainag'e,  if  employed,  may  be  either  l)y  the  tubular 
or  by  the  capillary  method.  The  route  from  the  pelvis  to  the  abdom- 
inal wound  is  l<mg  and  in  close  relations  with  the  bladder,  intestines, 


Figure  71. 


Vaginal  ^auze  drain  extending  from  Doiiglas's  pouch  to  the  vulva  for  papillary  drainage. 
A  large  gauze  pad  should  be  kept  over  the  vulva,  and  changed  often  enough  to  keep  it  drv.  This 
pad  IS  secured  by  a  T-bandage. 

and  omentum,  which  organs  should  have  no  necessary  relation  with  the 
held  of  operation,  but  which,  from  contact  with  the  drain,  are  unfortu- 
nately liable  to  infection,  adliesions,  perforation,  and  hernia.  More- 
over, the  long  sinus  left  after  removal  of  the  drain  is  often  slow  to  heal, 
and  its  outer  end  is  prone  to  contract  rapidly  and  leave  in  the  pelvis 
a  troublesome,  undrained  or  imperfectly  drained  pocket.  For  these 
reasons  the  abdominal  route  for  drainage  is  objectionable  and  should 
be  limited  to  special  cases. 

Fowler's  Position  and  Postural  Drainage. — If  abdominal  drain- 
age is  required  at  all,  it  should  be  most  thorough  and  is  best  secured 

10 


146 


GENERAL  PRINCIPLES. 


by  means  of  rubber  tubes,  an  inch  in  diameter,  split  on  one  side  the 
Aviiole  length,  and  containing  a  roll  of  gauze— cigaret  drain.  Three  of 
these  drains  should  be  used  :  one  in  each  ilank  and  one  in  the  cul-de- 
sac  of  Douglas.  The  patient  then  should  be  placed  in  the  exaggerated 
Fowler  position,  that  is,  the  shoulder  should  be  at  least  twenty  inches 
above  the  hips,  so  that  dependent  and  deep  depressions  in  the  perito- 


FlGURE 


Capillary  drainaee  through  abdominal  wound;  the  gauze  pad  held  by  the  hand  is  to  be 
placed  over  the  wound  in  contact  with  the  protruding  portion  of  the  drain.  This  pad  should 
be  secured  by  an  abdominal  binder,  and  changed  often  enough  to  keep  it  dry. 

neal  cavity  may  be  drained  by  gravity.  Such  drainage  is  demanded 
only  in  extreme  acute  cases  of  present  or  threatened  peritonitis  and 
should  be  undertaken  only  by  surgeons  of  great  experience  and  judg- 
ment. 

Vaginal  Drainage. — The  route  from  the  pelvic  cavity  to  the  vagina 
is  short  and  direct;  hence  the  vaginal  drain  is  generally  preferable. 
If  in  the  operation  an  opening  between  the  pelvic  cavity  and  the 
vagina  has  not  been  made  and  drainage  is  necessary,  it  is  often  better 


DRAINAGE  IN  MAJOR   OPERATIONS.  147 

to  make  an  opening  for  that  purpose.  The  great  advantages  of  the 
vaginal  route  are:  1,  minimum  risk  of  hernia;  2,  natural  and  de- 
pendent drainage  ;  3,  more  satisfactory  convalescence.  The  safety  of 
this  route  must  depend  largely  upon  previous  thorough  disinfection 
of  the  vagina. 

If  the  vaginal  gauze  drain  is  to  be  passed  after  an  abdominal  oper- 
ation through  an  opening  made  from  the  peritoneal  cavity  into  the 
vagina  for  that  purpose,  one  may  first  pack  the  strip  of  gauze  into  a 
previously  disinfected  vagina,  crowding  it  well  into  the  posterior 
vaginal  fornix,  where  it  easily  can  be  felt  Avith  the  finger  in  the  pouch 
of  Douglas.  The  operator  then,  using  this  packing  as  a  guide,  may  cut 
down  directly  upon  it.  This  incision  thus  made  may  be  enlarged  to 
the  required  degree,  and  the  gauze  already  being  in  place,  that  part 
of  the  operation  is  complete. 

The  manner  of  introducing  a  gauze  drain,  whether  abdominal  or 
vaginal,  is  as  follows :  The  end  of  a  continuous  strip  of  double  gauze, 
with  the  edges  turned  in  and  stitched  together  to  prevent  fraying,  is 
doubled  backward  and  forward  upon  itself,  like  the  folds  of  a  fan, 
from  the  part  to  be  drained  to  the  surface.  Over  this  an  external 
dressing  is  placed  and  changed  as  often  as  it  becomes  saturated.  Fig- 
ures 70,  71,  and  72  show  vaginal  and  abdominal  drains  in  place. 

The  time  for  removal  of  gauze  varies  with  the  purpose  for  which 
it  was  used  ;  if  to  control  hemorrhage,  it  should  be  removed  in  twenty- 
four  hours ;  if  for  drainage,  it  may  be  left  five  days,  unless,  as  occa- 
sionally happens,  it  acts  as  an  impediment  to  drainage.  Some  surgeons 
consider  the  gauze  objectionable  as  soon  as  it  becomes  saturated.  In  this 
connection  we  may  again  emphasize  the  importance  of  keeping  the  dress- 
ing over  the  dy-ain  absorbent  and  dry.  The  writer  repeatedly  has 
observed  patients  to  show  signs  of  septic  absorption  on  the  second  or 
third  day  after  an  abdominal  operation,  when  removal  of  the  gauze 
was  followed  by  a  gush  of  pent-up  fluid  and  prompt  relief  of  all 
urgent  symptoms.  It  is  not  usually  necessary,  after  removal  of  the 
original  drain,  to  introduce  fresh  gauze.  If  at  any  time  the  opening 
tends  to  contract  too  rapidly,  or  drainage  becomes  imperfect,  the  gauze 
may  be  renewed  or  a  tube  may  be  inserted. 

The  classical  dictum  has  been,  "  When  in  doubt,  drain.''  If,  how- 
ever, the  irritating  influence  of  the  drain  is  to  cause  the  secretion  of 
fluid  which  otherwise  would  not  be  secreted ;  if  the  peritoneum,  left  to 
itself,  is  capable  of  taking  up  and  disposing  of  large  quantities  of  fluid, 
even,  to  some  extent,  of  septic  fluid  ;  if  the  drain  is  more  prone  to  intro- 
duce than  to  carry  out  sepsis — then  the  dictum  may  have  to  be  reversed, 
when  in  doubt,  don't  drain. 


CHAPTER  VIII. 

AFTER-TREATMENT  IN  MAJOR  OPERATIONS. 

AFTER-TREATMENT    IN   SIMPLE    CASES. 

AVatchful  expectancy  is  the  rule  of  after-treatment  in  peritoneal 
surgery.  Indeed,  if  properly  performed,  an  abdominal  section  usually 
is  followed  by  normal  convalescence,  and  therefore  requires  little  or  no 
active  treatment. 

Importance  of  Rest. — Bodily  and  mental  rest  is  the  first  consid- 
eration. The  exclusion  of  relatives  and  friends  from  the  bedside  is 
usually  imperative,  and  will  not  be  difficult  if  properly  managed. 
They  have,  perhaps,  travelled  long  distances,  and  seriously  believe  that 
the  comfort  and  consolation  which  they  alone  can  give  are  highly 
essential  to  the  patient's  recovery.  They  must  be  told  in  kindly  but 
positive  words  that  the  results  of  experience  in  thousands  of  cases 
demonstrate  the  necessity  of  absolute  quiet ;  that  the  presence  of  the 
husband,  the  mother,  or  other  near  relatives  excites  emotion;  that 
emotion  consumes  energy,  of  which  the  patient  has  none  to  spare. 
Such  a  statement  is  usually  sufficient ;  if  not,  the  surgeon  must  enforce 
whatever  regulations  the  welfare  of  the  patient  may  demand.  If  she 
becomes  restless  and  anxious  because  the  relatives  are  kept  out,  it  may 
be  well  to  admit  them.  IMost  patients,  however,  during  the  first  two 
or  three  days  do  not  ask  for  them,  and  many  prefer  not  to  see  them. 
Frequently  sponge-bathing,  care  to  keep  the  bed-clothing  under  the 
patient  smooth,  and  such  other  minor  attentions  as  only  a  good  nurse 
can  suggest,  all  contribute  to  the  desired  end,  rest. 

Position. — The  expression  "absolute  rest"  is  misleading  if  it  im- 
plies the  enforcement  of  the  custom  of  keeping  the  patient  "abso- 
lutely on  her  back  during  the  first  two  or  three  days."  The  patient 
not  only  becomes  wearied  of  the  fixed  position,  but  is  apt  to  attribute 
to  it  the  inevitable  pain  and  discomfort  of  the  ansesthesia  and  opera- 
tion. Unless  there  is  some  special  objection,  she  should  freely  take 
whatever  position  is  most  comfortable.  She  will  then  wait  more 
patiently  for  the  natural  subsidence  of  the  discomfort,  which  if  all 
goes  well,  a  little  time  will  bring.  It  is  quite  safe  and  may  be  desir- 
able at  any  time,  if  the  patient  wishes,  to  elevate  the  head  and  shoul- 
ders on  a  back-rest,  even  to  the  extent  of  thirty  degrees. 

Fowler\s  Position,  which  is  secured  by  raising  the  head  of  the  bed 
from  ten  to  twenty  inches,  often  gives  relief  from  nausea  and  nervous 
irritation.  Many  surgeons  use  this  position  as  a  routine  measure  imme- 
diately after  operation. 

Rest  for  the  Stomach. — A  variable  degree  of  irritability  of  the 
whole  digestive  tract  is  the  common  result  of  ansesthesia,  especially 

148 


AFTER-TREATMENT  IN  MAJOR   OPERATIONS.  149 

in  cases  of  abdominal  section.  The  vomiting  and  nausea  of  this 
state  are  increased  rather  than  diminished  by  drugs  and  food.  The 
usual  treatment  is  to  withhold  them  until  the  effects  of  the  anaes- 
thesia have  passed  off.  A  teacupful  of  hot  water  slowly  given,  even 
though  promptly  thrown  up,  will  wash  out  the  stomach  and,  perchance, 
give  a  little  relief.  The  knees  may  be  drawn  up  into  the  most  com- 
fortable position  and  supported  on  a  pillow  or  roll.  The  judgment 
and  discretion  of  a  wise  nurse  will  furnish  a  guide  more  useful  than 
the  most  elaborate  rules.  The  best  nurse  will  move,  when  possible, 
along  the  lines  of  least  resistance,  or,  when  necessary,  wnll  use  a  gentle 
firmness  that  inspires  confidence.  She  will  carry  her  patient  past  the 
critical  period  with  the  minimum  of  friction  and  discomfort. 

Thirst. — "  Oh,  for  a  good  drink  !"  is  one  of  the  first  calls.  The 
common  practice  of  withholding  water  as  a  routine  is  to  be  condemned. 
In  the  absence  of  nausea  it  may  be  given  cold  or  hot  in  satisfying 
quantities.  Charged  waters,  ginger  ale,  champagne,  and  other  such 
drinks,  while  not  excluded,  are  not  required,  and  may  do  harm.  If 
water  is  not  tolerated  by  the  stomach,  a  pint  or  less  of  normal  salt 
solution  should  be  thrown  into  the  rectum  every  six  hours. 

If  in  the  preparatory  treatment  the  patient  has  taken  liberal  quan- 
tities of  water  for  several  days,  and  especially  if  before  closing  the 
wound  the  abdomen  has  been  filled  with  normal  salt  solution.  Chapter 
VII.,  there  will  be  little  complaint  of  thirst;  on  the  contrary,  there 
will  be  a  relative  freedom  from  nervousness  and  irritation. 

Hot-water  Bottles  and  Bags  placed  about  the  patient  imme- 
diately after  the  operation  are  useless  except  in  cases  of  shock,  and 
should  be  avoided  as  a  routine.  The  careless  use  of  hot-wdter  bottles 
or  rubber  bags  before  recovery  from  ancesthesta  has  resulted  occasion- 
ally in  serious  burns.  In  one  case  the  writer  observed  an  enormous 
blister  on  the  outer  surface  of  each  thigh  ;  in  another,  on  the  sole  of 
the  foot.  Both  patients  sustained  deep  sloughing  of  the  cutaneous 
and  subcutaneous  structures,  which  finally  required  extensive  skin- 
grafting.  As  the  freezing  of  water  in  a  pipe  more  readily  takes  place 
when  there  is  no  circulation  of  water,  so  in  conditions  of  shock, 
when  the  circulation  of  blood  is  feeble,  burns  are  more  liable  to  occur. 

The  Bowels. — If  the  temperature,  pulse,  and  respirations  are 
normal,  or  nearly  so,  and  there  is  no  abdominal  distention  nor  other 
unfavorable  sign,  movement  of  the  bowels  may  be  deferred  until  the 
second  day  ;  then  they  should  be  moved  by  an  enema  or  a  mild 
cathartic.  Some  surgeons  begin  immediately  after  the  operation  with 
half-grain  doses  of  calomel  given  every  fourth  hour  until  eight  or  ten 
doses  have  been  given  or  the  bowels  act.  If  there  is  no  action,  the 
calomel  is  followed  immediately  by  a  saline  purge,  or  an  enema,  or  both. 

Early  catharsis  is  a  good  precaution  against  sepsis  and  peritonitis, 
and  may  be  used  in  all  cases  in  which  these  complications  are  feared. 
In  normal  cases  it  is  unnecessary.  Early  movement  of  the  bowels, 
however,  is  desirable  in  all  cases.  After  the  initial  movement  they 
should  be  kept  regular  by  cathartics  or  enemas,  or  both. 

The  Bladder. — Great  caution  is  necessary  to  protect  the  patient 
against  tlie  deplorable  accident  of  distention  and  overflow  of  the  blad- 


150  GENERAL  PRINCIPLES. 

der.  Frequent  urination  should  always  excite  suspicion,  and  should 
be  regarded  as  an  urgent  indication  to  pass  the  catheter. 

Pain  of  variable  degree  is  usually  present  during  the  first  day  or 
two.  Opium  and  its  preparations  lock  up  the  secretions  induce 
nausea,  arrest  peristalsis,  cause  distention,  and  mask  any  symptoms 
which  otherwise  might  give  warning  of  approaching  danger;  they, 
moreover,  counteract  the  influence  of  cathartics,  and  would  prove 
therefore  a  serious  obstacle  if  it  became  necessary  to  move  the  bowels. 
Such  drugs,  if  given  at  all,  should  be  given  with  great  circumspection. 
Codeine  phosphate  creates  less  nausea,  constipation,  and  other  dis- 
turbances, than  opium  or  morphine ;  the  hypodermic  use  of  it  in  half- 
grain  doses  is  vSometimes  permissible,  during  the  first  twenty-four 
hours,  to  allay  nervous  irritation  and  pain  and  to  insure  needed  rest. 
There  are  conditions  of  great  nervous  irritation  in  which  morphine  in 
full  doses  is  indicated  strontrlv.  See  Hvsterical  Vomiting:  in  this 
chapter.  The  operator  is  largely  dependent  upon  the  wisdom  and  dis- 
cretion of  nurses  and  internes.  The  best  nurses  and  the  best  assistants 
manage  their  patients  with  the  least  morphine. 

Food. — Except  in  cases  of  exhaustion,  food  is  to  be  withheld  for 
one  or  two  days.  It  is  usual  to  begin  feeding  after  the  bowels  act  or 
flatus  passes.  Eructations  of  gas  from  the  stomach  are  an  indication 
for  withholding  food.  The  downward  passage  of  flatus  is  a  good 
prognostic  sign.  "Qui  crepitat  vitat"  said  the  early  Roman  physi- 
cians. The  diet  for  the  first  few  days  is  preferably  broth,  beginning  in 
small  doses  and,  according  to  the  tolerance  of  the  stomach,  gradually 
increasing.  A  teaspoonful  at  a  time  may  be  given  at  first,  and  re- 
peated in  thirty  minutes.  If  this  is  tolerated,  the  amount  may  after  a 
few  hours  be  doubled,  and  so  on  till  several  ounces  at  a  time  are  taken. 
Finally,  after  two  or  three  days,  if  all  goes  well,  the  amount  may  be 
increased  largely  until  full  quantities  are  taken. 

Getting  Up. — Ordinarily  the  ]iatient  may  sit  up  about  the  end 
of  the  second  week  ;  if  the  incision  was  long  and  union  is  not  quite 
firm,  she  should  be  kept  in  bed  longer. 

Care  of  the  Cicatrix. — If  the  sutures  were  non-absorbable  and 
have  been  removed,  the  wound  is  to  be  dressed  as  before,  except  with 
progressivelv  lighter  dressings,  for  a  period  of  two  weeks.  The  new 
cicatrix  should  be  supported  first  by  straps  of  adhesive  plaster,  and 
later,  when  the  patient  begins  to  walk,  by  a  properly  adjusted  elastic 
bandage.  A  variety  of  suitable  bandages  may  be  found  at  the  instru- 
ment or  dry-goods  shops.  The  bandage  should  be  worn  continuously 
in  daytime  for  six  months.  A  lighter  flannel  bandage  may  be  used  at 
night.  If  the  wound  was  closed  with  chromic  catgut,  as  described  in 
Chapter  VL,  and  is  not  more  than  two  or  three  inches  long,  and 
strong  union  has  taken  place,  no  abdominal  bandage  is  necessary. 

AFTER-TREATMENT  IN  COMPLICATED  CASES. 

Shock  associated  with  abdominal  section  is  the  same  as  after  other 
operations  and  injuries.  If  it  occurs  during  the  operation,  use  at  once 
the  extreme  Trendelenburg  position,  and  flood  the  peritoneal  cavity 


AFTER-TREATMENT  IN  MAJOR   OPERATIONS.  151 

with  a  quart  or  more  of  normal  salt  solution,  0.6  per  cent.,  at  a  tem- 
perature of  105°  F.,  and  complete  the  operation  as  soon  as  possible. 
After  the  operation  elevate  the  foot  of  the  bed.  Among  other  meas- 
ures for  the  treatment  of  shock  are  the  application  of  dry  heat  to  the 
surface ;  the  hypodermic  administration  of  strychnine  sulphate  every 
four  hours  in  doses  of  one-thirtieth  of  a  grain  each  ;  the  free  hypo- 
dermic use  of  whiskey,  at  least  four  drachms  every  hour ;  the  hypo- 
dermic injection  of  two  grains  of  camphor  dissolved  in  ten  minims  of 
sterilized  olive  oil,  to  be  given  every  hour;  and  copious  high  rectal 
enemata  of  warm  normal  salt  solution,  to  be  retained  if  possible. 
Shock  is  most  apt  to  occur  when  considerable  blood  has  Vjeen  lost 
during  the  operation  ;  whether  from  this  cause  or  not,  the  urgent  indi- 
cation is  to  fill  the  blood-vessels,  and  thereby  increase  arterial  pressure. 
See  Hypodermoclysis,  below. 

Secondary  Hemorrhage. — It  is  often  difficult  to  differentiate 
hemorrhage  from  shock.  The  former,  if  post  operative,  is  usually 
slow  and  may  not  declare  itself  until  several  hours  after  the  opera- 
tion. The  latter  more  commonly  begins  some  time  during  the 
operation. 

Diagnosis. — The  symptoms  of  hemorrhage  are  well  known.  The 
patient  has,  perhaps,  rallied  well  from  the  operation,  with  good  pulse 
and  temperature.  Presently,  or  within  a  few  hours,  there  are  symp- 
toms of  approaching  collapse — i.  e.,  rapid,  thready  pulse,  suVjnormal 
temperature,  pallor,  sighing,  gaping,  and  cold  surface.  If  these  symp- 
toms appear,  the  presence  of  much  clotted  blood  in  the  drainage-tube, 
if  there  be  one,  may  clear  the  diagnosis.  The  gauze  drain  would 
show  a  stain  of  deeper  red  than  ordinary  blood-serum  should  make. 
Both  of  these  signs,  however,  may  fail.  If  there  is  no  drain,  one  often 
may  work  a  small  glass  female  catheter  through  the  wound  between 
the  stitches.  Hemorrhage  then  would  declare  itself  by  the  presence 
of  clear  blood  in  the  catheter. 

Treatment. — To  reopen  the  wound,  find  the  source  of  hemorrhage, 
apply  a  ligature  or  a  pressure-forceps,  sponge  or  wash  out  the  cavity, 
and  close  the  wound  with  the  patient  bordering  on  collapse,  is,  indeed, 
a  serious  undertaking.  If,  however,  there  is  hemorrhage,  any  other 
attempt  to  check  the  bleeding  is  not  only  useless,  but  a  dangerous 
waste  of  time  as  well. 

Hypodermoclysis  after  Hemorrage. — A  most  effective 
means  of  combating  the  results  of  hemorrhage  is  the  hypodermoclysis 
injection  of  large  quantities  of  normal  salt  solution.  The  strength, 
according  to  Bacon,  should  be  not,  as  generally  directed,  0.6  per  cent., 
but  about  0.8  per  cent. — i.  e.,  8  parts  in  1000.  An  even  teaspoonful 
of  table  salt  in  a  pint  of  water  is  a  safe  and  reliable  approximation  to 
the  required  strength. 

The  technique  of  this  simple  and  valuable  procedure  is  as  follows : 
The  saline  solution  and  the  ap]iaratus  for  its  injection  are  sterilized  by 
boiling.  The  solution  having  been  boiled,  is  now  cooled  to  the  proper 
temperature,  say  110°  F,  The  surface  through  which  the  needles  are 
to  be  introduced  is  sterilized,  and  the  needles,  as  .shown  in  the  diagram, 
are  thrust  deeply  into  the  cellular  tissue  under  the  skin.    The  solution 


152 


GENERAL  PRINCIPLES. 


flows  from  the  bottle  or  funnel  by  its  own  weight.  An  elevation  of 
four  or  five  feet  is  necessary  to  make  the  fluid  flow  freely.  Constant 
gentle  massage  over  the  injected  area  will  promote  the  distribution 
and  absorption  of  the  fluid.  Ten  or  fifteen  minutes  usually  will  suffice 
for  the  introduction  of  a  pint  of  solution.  The  apparatus  consists  of 
a  glass  funnel  attached  to  a  large  hypodermic  needle,  single  or  double, 
by  means  of  a  long  rul)ber  tube.  The  fluid  passes  rapidly  into  the 
circulation,  immediately  increasing  arterial  pressure  ;  the  procedure 
gives  rise  to  little  or  no  pain.     It  is  sometimes  necessary,  after  an 

Figure  73. 


Apparatus  for  hj'podermoclysis.  The  funnel  contains  twenty  ounces.  A  rubber  tube,  with 
shut-off  attached,  connects  it  with  a  Y-shaped  glass  tube.  Two  small  rubber  tubes  connect 
this  with  aspirator-needles  or  large  hypodermic  points.  The  injection  may  be  thrown  into  the 
thighs,  abdominal  wall,  or  under  the'breasts.    The  submammary  region  is  usually  selected. 

exhausting  hemorrhage,  to  inject  at  intervals  into  the  breasts  or  abdom- 
inal wall  or  outer  surfkce  of  the  thighs,  as  much  as  three  quarts  in  a 
single  day. 

The  prime  indication  to  increase  arterial  pressure  is  ordinarily  more 
safely  and  quite  as  effectively  fulfilled  by  this  method  as  by  the  direct 
injection  of  blood  or  salt  solution  into  the  vessels.  When  the  loss  of 
blood  has  amounted  to  between  one-fourth  and  one-half  of  the  entire 
quantity  in  the  body,  some  prefer  to  throw  the  solution  directly  into  a 
vein.  This  demands  the  greatest  care  in  asepsis  and  extreme  pre- 
caution ag:ainst  the  introduction  of  air. 


AFTER-TREATMENT  IN  MAJOR    OPERATIONS.  153 

High  rectal  enemata  of  salt  solution  are  useful,  l)ut  less  rapidly 
effective  than  hypodermoclysis. 

Drop  Method  of  Salt  Water  Infusion.— If  not  very  immediate 
action  of  normal  salt  solution  is  desired,  one  may  use  with  great  satis- 
faction the  drop  method  of  infusion  into  the  rectum.  For  this  pur- 
pose the  apparatus  shown  in  Figure  73  should  be  modified  as  follows  : 
Substitute  a  small-calibre  rectal  tube  for  the  needles  and  introduce  this 
tube  high  into  the  rectimi.  Suspend  the  funnel  on  some  fixture  which 
will  hold  it  steady  about  four  feet  above  the  patient.  Hang  a  foun- 
tain syringe  bag  with  a  short  rubber  tube  above  the  funnel  in  such  a 
way  that  water  will  flow  from  the  bag  into  the  funnel.  Regulate  the 
current  to  a  drop-by-drop  supply  by  means  of  a  pressure  forceps  placed 
on  the  supply-tube,  so  that  the  solution  passing  drop  by  drop  into  the 
bowel  will  run  at  the  rate  of  not  over  a  pint  in  an  hour.  In  my  own 
practice  this  method  largely  takes  the  place  both  of  hypodermoclysis  and 
ordinary  enemata  of  salt  solution.    It  may  be  continued  for  many  hours. 

The  hemorrhage  having  ceased,  the  subsequent  treatment  is  the 
same  as  that  for  shock.  If  food  is  not  tolerated  by  the  stomach, 
rectal  alimentation  should  be  used  every  four  hours.  A  good  com- 
bination for  this  purpose  consists  of  the  white  of  an  egg,  three  ounces 
of  peptonized  milk,  and  one  ounce  of  whiskey. 

Sepsis. — The  phenomena  of  sepsis  often  are  considered  under  the 
name  peritonitis.  There  are  two  varieties:  first,  plastic  or  adhesive; 
second,  exudative.  In  the  plastic  variety  adhesions  may  form  around 
the  diseased  area ;  in  this  way  the  infection  may  be  shut  off  from  the 
general  peritoneum  and  confined  within  narrow  limits.  In  the  exuda- 
tive variety  the  plastic  or  defensive  action  is  absent  or  inadequate,  and 
the  infection  therefore  spreads  throughout  the  peritoneum  and  sets  up 
rapid  and  fatal  blood-poisoning.  It  is  a  mistake  to  attribute  the 
evils  of  sepsis  to  the  associated  peritonitis.  The  inflammatory  process 
is  an  effort  of  nature  to  protect  the  general  system  against  infection  : 
if  plastic  and  adhesive,  it  may  succeed  ;  if  exudative,  it  usually  fails. 
It  is  the  infection  that  specially  endangers  life,  not  the  associated 
peritonitis,  which  may  or  may  not  save  it.  Sepsis,  then,  or  to  use  a 
better  term,  infection,  may  clinically  be  classified  as  follows : 

1.  Localized  infection. 

2.  General  infection. 

1.  Localized  Infection. — This  usually  finds  expression  in  the  form 
of  an  abscess  at  the  seat  of  the  operation.  It  may  be  around  an  in- 
fected pedicle,  suture,  or  ligature.  The  nidus  may  be  a  surface  laid 
bare  in  the  operation  and  not  covered  by  peritoneum,  or  it  may  be 
pathological  tissue  which  could  not  be,  or  at  least  was  not,  removed. 
Localized  infection  is  apt  to  declare  itself  a  few  days  after  operation. 
The  prognosis  is  usually  good. 

The  symptoms  are  those  of  septic  absorption  :  rapid  but  usually 
strong  pulse,  varible  elevation  in  temperature,  localized  pain,  sweats, 
chilly  sensations,  with  little  or  no  tendency  to  collapse.  Examina- 
tion usually  will  show  a  progressively  enlarged  swelling  situated  in 
the  pelvis  and  felt  usually  on  conjoined  examination.  Stitch-abscess 
may  give  rise  to  the  same  symptoms,  but  usually  in  less  degree. 


154  GENERAL  PRINCIPLES. 

Treatment  is  simple  and  satisfactory.  Under  anaesthesia  the  abscess 
should  promptly  be  opened  and  drained.  The  drainage-channel  is 
usually  through  the  incision  by  which  the  peritoneum  was  entered  in 
the  original  operation — /.  e.,  through  the  abdomen  or  vagina.  If  a 
drainage-tube  is  already  in  the  wound,  there  may  be  spontaneous 
rupture  of  the  abscess  into  the  tube.  In  an  aggravated  case  it  is 
sometimes  best  to  make  through-and-through  drainage  from  the 
abdominal  wound  to  the  vagina.  Rubber  tubes,  not  gauze,  are  best 
for  drainage. 

In  case  of  stitch -abscess — that  is,  suppuration  in  the  line  of  the 
wound — the  sutures,  if  of  the  through-and-through  variety,  should  be 
removed,  if  of  the  buried  catgut  variety  they  should  be  left.  Any 
accessible  accumulation  of  pus  should  be  opened  with  a  blunt-grooved 
director  and  evacuated ;  then  the  wound  should  be  treated  with  a  95 
per  cent,  alcohol  gauze  dressing,  the  gauze  being  changed  often  and 
kept  wet  with  the  alcohol. 

2.  General  Infection  of  the  Peritoneum — i.  e.,  exudative  peritonitis, 
so-called — wdiich  is  apt  to  declare  itself  very  soon  after  the  operation 
— is  fatal.  Every  abdominal  surgeon  is  painfully  familiar  with  the 
characteristic  symptoms.  He  has  descried  them  from  afar  as  one  may 
discern  tbe  dark  cloud  upon  the  horizon.  In  the  balance  between  hope 
and  fear  he  has  watched  the  anxious  face,  the  drawn  expression,  the 
progressively  rising  temperature,  the  nausea,  at  first  attributed  to 
anaesthesia,  then  as  this  subsides  the  vomiting  of  sepsis  which  takes 
its  place,  the  frequent  regurgitation  of  bile  mixed  with  blood  and 
mucus  and  growing  darker  and  darker.  He  has  recognized  the  gradual 
failure  of  the  pulse,  first  weak,  then  running,  then  thready  to  the  van- 
ishing-point, the  paretic  and  distending  bowek,  which  refuse  to  act, 
the  rapid  respirations,  the  cold  extremities,  the  staring  eyes,  the  wide 
nostrils,  and,  finally,  the  inevitable  collapse. 

Treatment  is  useless.  The  symptom-group  just  outlined  may, 
however,  be  present  in  less  grave  conditions,  among  them  the  local, 
circumscribed  infection  above  described.  Bowel  distention,  vomit- 
ing, fever,  and  rapid,  weak  pulse  may  also  be  due  to  causes  other 
than  general  peritoneal  infection.  In  view  of  this  possibility,  there- 
fore, active  treatment  may  be  indicated. 

The  first  effort  should  be  directed  to  the  movement  of  the  bowels. 
Try  calomel,  one-half  grain  every  half-hour  until  the  bowels  have 
acted.  Let  this  be  followed,  if  necessary,  by  the  solution  of  citrate 
of  magnesium,  a  wineglassful  every  fifteen  minutes,  or  more  if  the 
stomach  will  tolerate  it.  In  obstinate  cases  a  single  soft  capsule 
containing  castor  oil  2  drachms  and  croton  oil  one-half  drop  will 
be  found  serviceable.  Copious  rectal  enemata  may  stimulate  the 
bowels  to  act,  or  at  least  to  expel  the  flatus.  The  enemata  may 
be  of  stiff  Castile  soapsuds,  with  a  drachm  of  turpentine  thoroughly 
mixed  in  each  pint.  It  may  be  a  mixture  of  glycerin,  Epsom  salt, 
and  water,  each  two  ounces,  or  a  quart  of  olive  oil  or  linseed  oil.  A 
large  enema  should  be  given  slowly  through  a  long  rectal  tube  intro- 
duced as  high  as  possible,  with  the  patient  on  the  left  side.  The 
muscular  walls  of  the  bowel  in  this   condition  are  generally  paretic  ; 


AFTER-TREATMENT  IN  MAJOR    OPERATIONS.  155 

hence  the  ^reat  difficulty  in  stimulating  them  to  contract  and  by  peri- 
stalsis to  expel  their  contents. 

Whiskey,  strychnine,  camphor,  ammonia,  rectal  alimentation,  and 
other  supporting  measures,  as  described  for  the  treatment  of  shock, 
may  be  used  in  moderation.  Under  such  management  patients  \vitli 
symptoms  like  those  of  general  peritoneal  infection  may  recov|'r. 

Crede's  ointment  of  argentum  colloidale,  one  drachm  a  day  thoroughly 
rubbed  in  for  two  to  twenty  minutes,  and  intravenous  injections  of  a 
2  per  cent,  emulsion  of  argentum  colloidale  once  a  day  in  doses  of  15 
grains,  are  among  the  strongly  recommended  measures.  Antistrep- 
tococcic serum,  given  hypodermically  10  to  40  cc.  a  day,  may  be 
useful  for  streptococcic  infection. 

The  free  use  of  powerful  toxic  drugs  as  a  routine  practice  is 
deplorable ;  desperate  conditions  do  not  necessarily  call  for  desperate 
measures ;  these  drugs,  unless  used  with  the  best  judgment,  may  take 
away  the  only  remaining  chance  for  life  from  a  patient  already  over- 
burdened with  the  toxaemia  of  sepsis. 

Hysterical  Vomiting. — In  about  1  per  cent,  of  abdominal  sections 
the  operation  is  followed  by  vomiting,  frequent,  violent,  prolonged, 
and  exhausting.  The  nervous  depression  is  profound  ;  the  pulse  may 
rise  to  170  or  180  to  the  minute.  The  condition  may  continue  for 
several  days,  with  final  recovery,  or  may  pass  into  collapse.  The 
pathology  of  this  phenomenal  nerve-storm,  with  the  stomach  for  the 
storm-centre,  is  unexplained.  It  may  be  due  to  toxsemia,  or  to 
irritation  similar  to  that  which  produces  the  vomiting  of  pregnancy. 
The  causes  are  widely  different  from  those  of  the  sepsis  above 
described.  There  is  little  or  no  fever  ;  the  temperature  may  be  sub- 
normal, as  in  shock ;  the  bowels  seldom  are  distended.  There  is 
simply  colossal,  almost  incessant,  vomiting  sometimes  even  to  the 
extent  of  fecal  vomiting.  Starvation  and  the  violent  exertion  of  the 
vomiting  soon  exhaust  the  patient. 

Treatment. — The  vomiting  sometimes  suddenly  ceases  without  ap- 
parent cause.  The  removal  of  the  sutures  or  of  a  drainage-tube  has 
been  followed  by  prompt  relief.  In  one  case  in  the  writer's  practice 
the  vomiting  promptly  and  permanently  ceased  upon  simply  re-open- 
ing the  lower  end  of  the  abdominal  wound  j  nothing  abnormal  was 
found,  and  the  wound  was  closed  immediately. 

The  diagnosis  once  made  to  the  exclusion  of  septic  peritonitis,  the 
treatment  is  simple  and  effective.  It  is  the  free  hypodermic  use  of 
morphine  in  doses  sufficient  to  allay  all  nervous  irritation,  to  induce 
sleep,  and,  above  all,  to  give  the  stomach  and  bowels  rest.  Under 
the  influence  of  morphine  food  is  retained,  and  in  two  or  three  days 
the  patient  recovers.  The  indication  also  is  for  hypodermic  injec- 
tions of  strychnine,  one-sixtieth  of  a  grain  every  four  to  six  hours, 
for  rectal  alimentation  and  for  washing  out  the  stomach  through  a 
stomach-tube. 

Obstruction  of  the  Bowels  as  a  post-operative  accident  is  not 
uncommon. 

Causes. — In  addition  to  non-surgical  causes  which  may  at  anv 
time  be  present,  there  are  those  causes  that  result  directlv'from  the 


156  GENERAL  PRINCIPLES. 

operation.  The  bowel  may  be  bent  sharply  upon  itself — /.  e.,  knuckled 
so  as  to  make  occlusion  at  the  point  of  flexure.  If  at  the  same  time 
adhesions  form  at  or  near  the  point  of  flexure,  immobilization  takes 
place  ;  the  bowel  cannot  straighten  itself,  and  o])struction  is  estab- 
lished. Sometimes  a  part  only  of  the  circumference  of  the  bowel  is 
constricted  either  in  a  hernial  opening — Littre's  hernia — or  between 
bands  of  adhesion.  The  diverticulum  looks  like  a  nipple  as  it  pro- 
trudes from  the  convex  surface  of  the  intestinal  loop.  On  relieving 
the  constriction  the  nipple  disappears,  leaving  a  deeply  indented,  dark- 
blue  ring.  This  form  of  hernial  obstruction  is  partial,  and  therefore 
less  severe  than  when  the  bowel  is  occluded  entirely.  Vomiting  is 
less  :Cree  and  less  apt  to  be  fecal.  Flatus  in  small  quantities  may  con- 
tinue to  pass.  The  downward  passage  of  feces  is  not  always  wholly 
interrupted.  In  cases  of  vaginal  section  when  the  wound  is  left  open 
and  the  gauze  drain  used,  the  space  occupied  by  the  drain  may  upon 
the  removal  of  the  drain  receive  a  mass  of  intestine.  The  result  may 
be  adhesion  and  obstruction.  Occasionally  a  loop  of  bowel  works  its 
way  between  the  margins  of  the  wound  and  becomes  pinched,  occluded, 
and  adherent.  This  is  not  a  very  infrequent  result  of  capillary  vaginal 
drainage.  The  evils  of  drainage  have  been  stated  more  fully  in  Chap- 
ter vii. 

Clearly,  adhesions  are  more  apt  to  occur  between  surfaces  not  cov- 
ered with  peritoneum  ;  hence  the  importance  of  careful  plastic  work 
during  the  operation,  to  cover,  so  far  as  possible,  all  exposed  surfaces. 

Acute  obstruction  frequently  has  followed  the  use  of  solid  food  too 
soon  after  an  abdominal  operation. 

Diagnosis  and  Prognosis. — It  is  important  to  distinguish  mechani- 
cal obstruction,  due  to  kinking,  intussusception,  or  adhesions,  from 
mere  failure  of  the  paretic  bowel  to  act.  The  two  conditions  may 
resemble  one  another  so  closely  as  to  make  the  distinction  impossible. 
Reverse  peristalsis  and  consequent  fecal  vomiting,  a  common  symptom 
of  obstruction,  seldom  occurs  in  paresis.  The  bowel  may  be  paretic 
from  a  grave  cause  like  septic  peritonitis,  or  from  some  trivial  cause. 

The  diagnosis  is  the  same  as  for  obstruction  of  the  bowel  from 
other  causes.  J^fausea,  vomiting,  first  of  bile,  finally  of  feces,  abdom- 
inal distention,  and  rapid  pulse  are  among  the  prominent  symptoms. 
Peritonitis  is  first  local  and  confined  to  the  affected  part ;  but  later 
may  become  general.  Death  usually  follows  within  a  few  days,  unless 
the  patient  is  relieved  by  surgical  means. 

Treatment. — Before  proceeding  to  the  dangerous  operation  of  re- 
opening the  wound  and  looking  for  the  cause  of  obstruction  an  attempt 
should  be  made  to  secure  relief  by  means  of  high  rectal  enemas  and 
position.  In  an  aggravated  case  of  apparent  mechanical  obstruction 
in  which  the  abdomen  is  distended  to  the  size  of  full-term  pregnancy 
and  strenuous  attempts  to  secure  action  of  the  bowels  by  means  of 
enemas  and  cathartics  have  failed,  the  following  measures  may  give 
prompt  relief :  1.  Croton  oil,  one-half  drop  to  one  drop;  2.  A  hot 
stupe  of  25  per  cent,  turpentine  covering  the  entire  abdomen,  the 
dressing  over  the  wound  having  all  been  removed  in  order  that  the 
stupe  may  be  applied  directly  to  the  skin ;  3.  Frequent  change  in  the 


AFTER-TREATMENT  IN  MAJOR   OPERATIONS.  157 

position  of  the  patient,  especially  turning  on  the  abdomen.  It  is  most 
essential  to  distinguish  between  obstruction  from  shutting  oif  the 
lumen  of  the  bowel  and  simple  failure  of  action  from  other  causes,  for 
in  actual  obstruction  cathartics  might  do  much  harm. 

The  diagnosis  of  mechanical  obstruction  once  established,  no  time 
should  be  lost  in  the  attempt  to  relieve  the  bowels.  If  the  obstruc- 
tion has  been  continuous  for  thirty  hours,  and  upon  reopening  the 
abdomen  the  operator  cannot  immediately  locate  the  cause  of  it  and 
promptly  open  the  way  through  it,  the  safer  treatment  would  Ije  to 
establish  an  artificial  anus,  even  though  a  later  operation  may  be 
necessary  to  restore  the  integrity  of  the  bowel  and  close  the  sinus. 

Obstruction  and  paresis  are  much  less  likely  to  occur  if  the  bowels 
have  been  relieved  thoroughly  of  feces  and  gas  before  the  operation. 
See  Preparatory  Treatment  in  Chapter  II. 

Sinuses. — The  localized  infection  described  in  a  preceding  para- 
graph commonly  subsides  on  drainage.  Sometimes  the  source  of 
infection  is  continuous;  then  the  drainage-track  becomes  a  sinus,  and 
may  continue  to  transmit  pus  until  the  infective  substance  is  removed. 
This  substance  is  usually  an  infected  ligature  or  intra-abdominal  suture 
which  refuses  to  be  cast  off.  It  may  remain  for  months  or  years  a 
continual  nidus  of  infection  and  suppuration,  or  may  at  any  time  come 
away.  Spontaneous  closure  of  the  sinus  upon  removal  of  the  infec- 
tive substance  is  the  almost  invariable  rule.  If  not  spontaneously 
thrown  otf,  such  ligatures  or  sutures  often  may  be  caught  and  fished 
out  by  means  of  an  instrument  acting  on  the  principle  of  a  crochet- 
needle,  or  by  means  of  a  very  small  dull  curette.  Should  these  fail 
and  the  discharge  continue  for  a  number  of  months,  the  indication  is 
to  cut  down  and  remove  the  offending  cause.  The  operation  is  usually 
simple  and  relatively  safe.  An  incision  through  the  abdominal  wall 
in  the  track  of  the  original  wound  commonly  enables  the  operator  to 
dilate  the  deeper  part  of  the  sinus  and  seize  the  ligature ;  if  not,  the 
adherent  viscera  may  be  separated  carefully  until  the  nidus  is  reached 
and  removed. 

Long-continued  suppuration  is  a  reproach  to  the  surgeon  ;  it  is 
annoying,  irritating,  and,  even  though  slight,  tends  to  produce  degen- 
eration of  the  kidneys  and  other  important  organs ;  hence  the  neces- 
sity of  efficient  methods  for  the  prevention  of  it  or  for  removal  of 
the  offendinir  source. 

Prevention. — The  use  of  absorbable  catgut  sutures  and  ligatures, 
which  may  be  sterilized  absolutely — see  Chapter  II. — is  a  most  satis- 
factory preventive.  Silk,  silkworm-gut,  metallic,  and  other  non- 
absorbal)le  sutures  and  ligatures,  for  the  reasons  indicated,  are  not 
generally  advised  in  peritoneal  surgery. 

Fecal  Fistula. — The  bowel  during  an  operation  may  be  opened, 
or  so  injured  that  an  opening  is  liable  to  occur  later.  In  either  event 
the  injury  should  be  repaired  before  closing  the  abdomen.  In  a  small 
proportion  of  such  cases  the  sutures  fail,  or  the  bowel  opens  at  some 
unsuspected  point.  The  result  usually  is  local  infection,  as  already 
described,  followed,  if  the  patient  survives,  by  a  fecal  fistula  with 
discharge  of  the  bowel-contents  through  a  sinus  in  the  wound. 


158  GENERAL   FPdNCIPLES. 

The  fistula,  in  a  majority  of  cases,  if  left  a  few  days,  weeks,  or 
months,  will  close  spontaneously.  Closure  is  usually  more  prompt  in 
sinuses  through  the  vaginal  than  through  the  abdominal  wound.  The 
explanation  of  this  may  be  that  the  sinus  is  shorter  and  the  vaginal 
wound  less  accessible,  and  therefore  less  tampered  with  by  the  surgeon. 
If  the  fistula  does  not  finally  heal,  an  operation  for  the  closure  of  it 
may  be  necessary. 

Urinary  fistula  follows  the  same  general  laws  as  fecal  fistula.  The 
former  seldom  occurs  except  when  the  bladder  or  the  ureter  has  acci- 
dentally been  opened  in  the  operation  and  the  sutures  for  its  closure 
have  failed.  The  presence  of  the  fistula  is  recognized  by  the  ap- 
pearance of  urine  in  a  sinus  opening  through  the  wound.  The 
treatment  is  to  introduce  a  self-retaining  catheter  and  keep  it  in  the 
urethra  until  the  fistula  closes.  Secondary  sutures  seldom  are  required. 
A  ureteral  opening  is  more  serious  and  requires  special  operative 
measures.     See  Chapter  XLIII. 

Stitch-abscess. —  Suppuration  in  the  abdominal  Avound  usually 
may  be  avoided  by  scrupulous  asepsis.  If  it  occurs,  the  sutures, 
unless  buried,  should  be  removed,  and  gauze  saturated  Avith  95  per 
cent,  alcohol  should  be  applied,  and  changed  frequently.  The  alcohol 
dressing  should  be  continued  until  healing  is  complete.  In  aggravated 
cases  the  abscess  may  have  to  be  opened  and  drained. 

Removal  of  Sutures. — One  carelessly  may  cut  the  loop  on  both 
sides  of  the  knot ;  in  such  a  case  the  ends  of  the  loop  retract  below 
the  surface  and  cannot  be  reached.  If  the  loop  does  not  become 
encysted,  there  may  be  suppuration  around  it,  which  will  persist  until 
it  M'orks  out,  is  fished  out  with  a  crochet-needle,  or  is  removed  through 
an  incision.     Figure  44. 

Ventral  Hernia. — The  chief  causes  of  ventral  hernia  in  connec- 
tion with  al)dominal  operations  are  the  drainage-tube — see  Drainage — 
improper  closure  of  the  wound,  and  want  of  proper  support  to  the 
abdomen  by  elastic  bandages  during  the  first  few  months  after  the 
operation.  The  longer  the  incision  and  the  thinner  the  abdominal 
wall  the  greater  the  need  of  the  bandage ;  incisions  not  more  than 
two  inches  long,  if  properly  closed,  seldom  require  it.  The  treatment 
is  to  reopen  the  abdomen  through  or  near  the  old  cicatrix,  split  the 
sheaths  of  the  recti  muscles,  and  reunite  the  wound  as  already  directed 
lor  ordinary  closure  of  an  abdominal  wound. 


CHAPTER  IX. 

THE  KELATIONS  OF  DRESS  TO  THE  DISEASES  OF 

WOMEN.i 

Manner  of  living,  environment,  food,  sleep,  work,  rest,  recrea- 
tion, exercise,  and  clothing  necessarily  must  have  a  determinate  in- 
fluence on  the  prophylaxis  and  cure  of  disease.  The  gynecologist, 
therefore,  who  gives  to  this  subject  its  true  weight  will  stand  upon  a 
decided  vantage-ground  over  that  one  whose  resources  are  limited  to 
drugs,  local  treatment,  and  operative  measures.  One  of  the  most 
serious  of  all  obstacles  to  the  prevention  and  cure  of  the  diseases  of 
women  is  fashion  in  dress. 

So  long  as  sensible  dress  appears  eccentric  and  excites  ridicule 
women  will  adhere  to  the  prevailing  modes,  and  will  therefore  be 
hampered  not  only  in  the  pursuit  of  recreation  and  exercise,  but  also 
in  the  performance  of  the  more  essential  physiological  functions. 
Under  such  conditions  fashion  must  continue  to  prevail  against  strong 
nerves,  powerful  muscles,  and  robust  health.  As  soon  as  the  girl 
passes  from  the  nursery  to  the  drawing-room,  and  the  dress  of  child- 
hood is  changed  for  tlie  conventional  dress  of  fashion,  some  of  the 
evils  of  what  we  call  civilization  become  manifest.  She  can  neither 
walk,  run,  nor  even  breathe  without  embarrassment.  The  fact  that 
women  has  endured  and  survived  the  tyranny  of  dress  for  centuries 
without  more  serious  results,  says  Emmet,  is  convincing  proof  of  her 
power  of  endurance. 

The  prevention  and  cure  of  the  diseases  peculiar  to  women  require 
the  fulfilment  of  three  principal  conditions  in  dress  : 

1.  Even  distribution  for  uniform  protection  against  cold  and  wet. 

2.  Freedom  from  waist   constriction. 

3.  Freedom  from  traction. 

1.  Even  Distribution. — Uneven  distribution  is  conspicuous  in  the 
prevailing  modes  of  dress.  The  undergarments  are  usually  of  cotton 
or  other  light  material  and  are  often  sleeveless  and  low  in  the  neck. 
Numerous  skirts  hang  about  the  lower  extremities  and  give  them 
relatively  little  protection.  The  outer  garments  are  usually  of  thin 
material,  and,  according  to  the  caprice  of  fashion,  may  or  may  not 
cover  the  arms,  neck,  and  upper  part  of  the  bust.  The  bonnet  is  use- 
less for  protection.  The  feet  often  are  held  in  the  vice-like  grasp  of 
thin,  high-heeled  coverings  which  more  resemble  stilts  than  shoes. 
They  fliil  to  protect  the  woman  against  cold  and  prevent  free  exer- 
cise. In  contrast  with  such  inadequate  protection  for  the  upper  and 
lower    extremities,   the  waist  and   hips  are   swathed  and  compressed 

T?n>,lJA®  ^Titej'  in  this  presentation  of  the  subject,  has  adapted  freely  from  the  works  of 
Kobert  L.  Dickinson,  of  Brooklyn,  and  J.  H.  Kellogg,  of  Battle  Creek. 

159 


160 


GENERAL  PRINCIPLES. 


in  a  "  torrid  zone "  of  whalebone,  corsets,  belts,  steels,  skirts,  and 
other  cumbersome  material. 

2.  Waist  Constriction  comes  chiefly  from  the  corset,  which  not 
only  constricts  the  waist,  but  also  dislocates  the  thoracic  viscera  up- 
ward and  the  abdominal  viscera  downward.  It  restrains  the  abdom- 
inal and  dorsal  muscles,  and  may  cause  them  to  atrophy  from  disuse. 
It  prevents,  by  its  stiffness,  the  undulatory  movements  of  the  abdom- 
inal walls  and  restricts  peristalsis. 

Normal  breathing  requires  the  lungs  to  be  expanded  in  all  direc- 
tions, and  is  therefore  not  costal  nor  abdominal,  but  a  combination  of 
both.  AVaist  constriction  immobilizes  the  abdomen,  and  thereby  pre- 
vents abdominal  breathing.  Tiiis  involves  a  loss  in  lung-power  which 
cannot  be  supplied  by  any  compensatory  increase  in  costal  breathing. 


Figure  74. 


LUNG 

LI  VER 

5TOMAC 

KIDNEY 


The  left-hand  figure  is  corset-deformed,  with  the  thoracic  and  abdominal  organs  displaced 
The  right-hand  figure  is  normal,  with  the  thoracic  and  abdominal  organs  in  place. 

Moreover,  the  diaphragm  from  upward  pressure,  and  the  pehic  floor 
from  downward  pressure,  are  rendered  inactive  and  atrophic,  and 
are  thereby  unable  to  make  their  upward  and  downward  movements 
which  normally  should  be  transmitted  to  the  abdominal  and  pelvic 
viscera.  The  physiological  importance  of  these  respiratory  move- 
ments is  very  great.  Tliey  are  a  sort  of  natural  massage.  The 
descent  of  the  diaphragm  M^ith  each  inspiration  increases  pressure  in 
the  abdominal  cavity  and  lessens  that  in  the  chest.  Tlie  reverse  of 
this  occurs  with  expiration. 

Alternating  pressure  and  relaxation  upon  the  blood-  and  lymph- 
vessels  secure  free  circulation.  Alternating  contraction  and  relaxation 
of  the  muscular  bundles  of  the  uterine  ligaments  and  of  the  other 
elastic  and  muscular  parts  of  the  pelvic  floor  serve  to  maintain  their 


THE  RELATIONS  OF  DRESS  TO   THE  DISEASES  OF  WOMEN.     161 

normal  nutrition  and  tone.  Alternating  rest  and  motion  are  essential 
to  the  health  of  the  organs  and  their  supports ;  waist  constriction  im- 
mobilizes them  and  stops  their  physiological  movements.  The  pelvic 
veins  empty  iigito  the  greatest  area  of  corset  pressure ;  the  long  and 
perpendicular  column  of  blood  of  this  area  is  by  such  pressure 
dammed  back  upon  the  pelvic  organs,  especially  upon  the  ovaries. 
The  consequence  is  passive  congestion,  an  unfailing  source  of  disease. 
Even  the  loosely  worn  corset  excites  great  downward  pressure  when- 
ever the  woman  stoops  forward,  as  she  must  do  in  sitting  and  rising. 
Sewing-women,  clerks,  writers,  and  students,  who  wear  corsets,  are 
especially  subject  to  this  evil.^ 

The  garter  is  injurious  from  its  tendency  to  obstruct  the  venous 
circulation  in  the  legs. 

3.  Freedom  from  Traction. — The  abdominal  and  dorsal,  muscles 
and  the  hips  have  to  carry  the  weight  of  numerous  skirts  and  such 
other  garments  as  usually  oppress  that  area.  In  the  eifort  to  sustain 
this  weight  the  muscles  become  permanently  tired,  lose  their  tonicity, 
and  are  powerless  to  prevent  a  still  further  increase  of  downward 
pressure  upon  the  pelvic  floor  and  pelvic  organs. 

Figure  74  is  given  to  illustrate  some  of  the  evils  of  undue  pressure 
and  uneven  traction. 

To  compare  ordinary  modes  of  dress  with  those  which  give  freedom 
of  motion,  "one  has  only  to  look  at  a  lot  of  girls  on  the  way  to  the 
gymnasium,"  said  a  Vassar  teacher.  "  They  drag  along  ;  they  have 
no  spirit  nor  spring  in  them  ;  they  are  in  their  ordinary  clothes.  Look 
at  the  same  set  coming  on  the  gymnasium  floor  in  their  light  toggery ; 
they  skip  and  dance  and  run  in  the  liberty  of  unrestrained  and  un- 
trammelled motion ;  they  are  different  beings." 

In  laying  aside  waist  constriction  avoid  half-way  measures,  such  as 
loosening  the  corset  or  substituting  the  so-called  health-waist,  which 
too  often  is  only  an  aggravated  form  of  corset.  Leaving  off  the  cor- 
set altogether  and  retaiuing  the  numerous  skirts  with  their  bands  and 
belts  to  drag  upon  the  waist  and  hips  rather  increase  than  lessen  the 
evil.  The  only  judicious  compromise  is  temporary  support  by  means 
of  a  suitable  waist  having  little  or  no  stiflFness,  which  shall  cover  the 
shoulders,  and  upon  which  skirts,  drawers,  and  other  garments  may 
be  buttoned,  so,  that  their  weight  may  be  distributed  over  the  shoulders. 
This  should  be  worn,  if  at  all,  only  during  the  period  of  aggravated 
weakness,  especially  weakness  of  the  back,  which  follows  the  with- 
drawal of  the  corset  and  continues  until  the  weakened  abdominal 
muscles  have  regained  their  tone. 

The  conventional  dress  has,  until  recently  at  least,  consisted  of 
nine  garments  four  hanging  from  the  shoulders  and  five  from  the 
waist,  namely : 

1.  Undershirt. 

2.  Chemise. 

3.  Corset-cover. 

4.  Dress  waist. 

^^Adapted  from  R.  L.  Diokinson.    Hare's  System  of  Practical  Therapeutics,  vol.  iii   pp. 
11 


162  GENERAL  PRINCIPLES. 

5.  Uuderdrawers. 

6.  White  drawers. 

7.  Corset. 

8.  Flannel  skirt. 

9.  Dress  skirt. 

Counting  each  band  as  two  thicknesses,  these  make  seventeen 
layers  about  the  waist ;  and  allowing  twenty-five  inches  as  waist  cir- 
cumference, these  seventeen  layers  if  joined  end  to  end  would  make 
a  bandage  thirty-four  feet  long. 

Hygienic  dress  requires  four  garments,  namely  : 

1.  Union  undergarment. 

2.  Equestrienne  tights. 

3.  Muslin  waist  and  skirt. 

4.  Dress  in  one  piece,  or  so  made  that  its  principal  weight  may 

be  distributed  over  the  shoulders,  bust,  and  hips.      This 
makes  four  layers  about  the  waist. 

1.  The  union  undergarment  is  a  union  of  the  undershirt  and 
drawers  in  one  piece ;  the  open  stride  is  supplied  with  the  broad  flap, 
as  a  protection  to  the  external  genitalia  and  to  guard  the  other  gar- 
ments from  their  secretions.  The  material  of  the  suit  may  be  silk, 
wool,  or  cotton,  or  any  mixture  of  these.  In  winter  it  should  be 
heavy,  with  high  neck  and  long  sleeves,  and  should  reach  to  the  ankle. 
In  summer  it  may  be  lighter,  with  lower  neck  and  short  sleeves,  and 
should  reach  to  the  knee. 

2.  The  equestrienne  tights  are  the  substitute  for  the  heavy  woollen 
petticoat,  and  are  designed  for  out-door  use  in  winter.  They  reach 
from  waist  to  ankle,  corresponding  to  the  man's  trousers. 

3.  The  muslin  skirt  and  waist  often  are  made  in  one  piece,  but 
there  are  practical  advantages  in  making  them  separate.  The  waist, 
if  separate,  should  reach  well  down  over  the  hips,  and  the  skirt,  made 
without  band,  should  be  buttoned  to  it.  The  open  stride  of  women's 
garments  is  a  great  source  of  infection,  since,  in  conjunction  with  the 
dust-sweeping  skirts,  it  exposes  the  external  genitals  to  the  entrance 
of  dust  and  other  fine  particles,  which  are  always  irritating  and  often 
the  vehicle  of  infectious  bacteria.  Closed  muslin  drawers  are  there- 
fore desirable  as  a  means  of  protection,  and  these  also  may  be  buttoned 
to  the  waist. 

4.  The  dress  may  be  in  one  piece,  after  the  "  princess "  pattern  ; 
or,  if  in  two  pieces,  the  skirt,  unless  too  heavy,  may  be  attached  to 
the  waist  with  hooks,  in  which  case  its  lining  may  be  continued  over 
the  shoulders  in  the  form  of  a  carefully  fitted  skeleton  waist. 

The  garments  just  described  may  be  modified  in  many  ways  to  suit 
individual  taste  and  changing  fashion,  but  the  essential  principle  must  be 
observed,  viz. :  uniform  distribution,  freedom  from  undue  weight  and 
traction,  and  freedom  from  constriction.  Light  whalebones  may  be 
useful  in  the  waist-seams  for  very  stout  women  with  pendulous  breasts. 
Proper  dress  and  consequent  freedom  of  motion  will  stimulate  the 
woman  to  out-door  exercise  and  in-door  gymnastics,  which,  if  followed 
with  system  and  perseverance,  usually  will  give  normnl  tone  to  the 
abdominal  and  thoracic  muscles  and  normal  firmness  to  the  breasts. 


THE  RELATIONS  OF  DRESS  TO   THE  DISEASES  OF    WOMEN.     163 

Artificial  support,  therefore,  except  in  aggravated  cases,  is  to  be  dis- 
couraged. 

Union  undergarments  of  all  grades  and  descriptions,  adapted  to  the 
needs  and  circumstances  of  all  classes,  now  may  be  found  in  the  shops. 
Economy,  health,  comfort,  and,  to  the  properly  educated  sense,  beauty, 
all  combine  on  the  side  of  proper  dress.  It  is  marvellous  that  the 
monstrosities  of  fashion  have  overshadowed  so  completely  the  natural 
beauty  of  form  and  figure.  From  the  standpoint  of  beauty  shall  we 
choose  the  natural  lines  of  the  body  or  the  artificial  lines  of  the  corset, 
the  garment  fitted  to  the  woman  or  the  woman  fitted  to  the  garment? 
Imagine  the  attempt  to  add  to  the  dignity  of  the  lion  or  to  the  beauty 
and  grace  of  the  greyhound  by  the  use  of  artificial  means  to  change 
the  natural  lines  of  their  bodies.  Throwing  aside  the  all-controlling 
bias  of  fashion,  who  shall  say  that  the  woman  is  so  inferior  to  the 
lower  animals  in  form  and  figure  that  she  must  be  taken-in  in  some 
places  and  let-out  in  others  ?  In  this  connection  the  words  of  Her- 
bert Spencer  have  peculiar  force :  "  Nature  is  made  better  by  no 
mean,  but  Nature  makes  that  mean  ;  over  that  art  which  you  say  adds 
to  Nature,  is  an  art  that  Nature  makes. 


PART  II. 

INFECTIONS,  INFLAMMATIONS,  AND 
ALLIED  DISORDERS. 


CHAPTEK   X. 

GENERAL  CONSIDERATIONS  OF  INFECTION  AND  INFLAM- 
MATION OF  THE  REPRODUCTIVE  ORGANS. 

Infection  of  any  one  of  the  reproductive  organs  is  liable  to  have 
the  closest  relations  to  similar  infection  of  a  part  or  all  of  the  others ; 
for  this  reason  an  intelligent  consideration  and  satisfactory  explanation 
of  the  morbid  process  in  any  one  organ  may  necessitate  a  study  of 
infection  in  the  pelvic  organs  as  a  whole.  The  distinction  between 
infection  and  inflammation  is  of  the  greatest  practical  importance. 

Definition  of  Infection. 

Infection  is  that  condition  in  which  foreign  media  of  irritation 
have  gained  access  to  an  organ,  and  either  mechanically  or  by  means 
of  their  products,  disturbed  its  functions.  These  media  are  capable 
of  being  transmitted  to  other  organs  and  other  individuals.  In  most 
cases,  at  least,  the  invading  irritant,  if  known,  is  of  bacterial  origin. 
The  organisms,  unless  arrested,  are  prone  to  multiply  rapidly,  to 
invade  new  territory,  to  transmit  themselves  and  their  toxic  prod- 
ucts to  the  general  circulation,  and  to  destroy  or  seriously  endanger 
the  life  of  the  patient. 

Definition  of  Inflammation. 

The  local  territory  irritated  by  the  organisms  and  their  toxins 
becomes  a  centre  to  which  leucocytes  in  variable  numbers  rapidly 
migrate,  and  in  this  way  the  process  often  called  seroplastic  infiltra- 
tion is  established.  By  this  infiltration  a  limiting  wall  is  formed 
around  the  infected  space.  This  wall  confines  the  infective  process 
to  narrow  limits,  and  may  protect  the  general  system  against  the 
toxins.  The  formation  of'the  limiting  wall  gives  rise  to  heat,  red- 
ness, pain,  and  swelling  :  this  is  inflammation.  In  view  of  these  facts, 
inflammation  is  not  really  the  disease,  but  an  effort  to  limit  the  dis- 
ease. The  almost  universal  use  of  the  word  inflammation  to  signify 
the  disease  makes  it  difficult  in  the  description  of  the  morbid  proc- 

165 


166  INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

esses  to  conform  to  the  ideas  above  expressed.  The  attempt  will, 
however,  be  made  to  use  the  two  words  infection  and  inflammation  in 
their  proper  relations. 

Etiology  of  Infection  and  Inflammation. 

It  is  important  to  remember  that  the  study  of  a  morbid  process  in 
an  organ  or  group  of  organs  is  simply  the  study  of  their  anatomy  and 
physiology  as  modified  by  that  process.  The  inflammatory  process 
has  been  defined  as  the  reaction  'svhich  living  tissue  exhibits  to  morbid 
irritation.  This  definition  being  correct,  two  conditions  must  be 
essential  for  the  development  of  infection  and  inflammation  :  The  soil 
must  be  prepared  and  ready  to  react  to  the  morbid  irritation.  Clearly, 
tissue  which  has  the  power  to  resist  the  irritation  and  to  hold  it  within 
physiological  bounds  will  not  inflame.     There  must  then  be : 

1.  Favoring  conditions. 

2.  Exciting  causes. 

1.  Favoring  Conditions. — The  various  so-called  diatheses,  such 
as  gout,  rheumatism,  anaemia,  diabetes,  lithsemia  and  cholsemia,  hav^e 
been  set  down  as  favoring  conditions  which  act  as  predisposing  causes 
of  infection  in  the  pelvic  organs,  but  the  exact  relation  which  they 
have  to  the  infection  is  somewhat  speculative. 

Local  favoring  conditions  are  apparent  in  the  anatomical  and  physi- 
ological arrangement  of  the  pelvic  organs.  The  genital  tract,  from 
the  vulva  to  the  peritoneum,  is  an  open  canal,  patent  to  the  atmosphere 
below  and  terminating  above  in  the  free  open  ends  of  the  Fallopian 
tubes.  It  is  not  only  open  to  such  microbic  germs  as  abound  in  the 
air  and  penetrate  everywhere,  but  is  also  a  place  of  deposit  for  viru- 
lent bacteria. 

Rupture  of  the  capillary  vessels  of  the  endometrium  in  men- 
struation and  of  the  Graafian  follicles  in  ovulation,  although  physi- 
ological, results  in  solutions  of  continuity  and  in  hemorrhage,  and  is 
therefore  traumatic.  These  traumatisms  and  the  menstrual  engorge- 
ment of  the  pelvic  organs  nuder  healthy  conditions  pass  by  with 
little  or  no  discomfort ;  but  if  some  morbid  irritation  upset  the 
normal  balance  of  nutrition,  the  menstrual  congestion  may  become 
pathological  and  may  be  the  first  stage  of  an  inflammation.  Morbid 
congestion,  though  less  frequently,  also  may  be  set  up  in  the  inter- 
menstrual period  independently  of  the  menstrual  congestion. 

In  addition  to  the  physiological  traumatisms  already  mentioned, 
the  traumatisms  of  parturition,  of  abortion,  of  improper  local  treat- 
ment, and  of  operations  still  further  open  the  way  for  the  entrance 
of  infection.  Violent  coitus,  masturbation,  the  careless  use  of  the 
unclean  catheter,  impure  water  in  bathing,  and  soiled  linen  in  the 
toilet  are  some  of  the  means  by  which  gonorrhoeal,  syphilitic,  and 
other  infections  may  develop  in  the  genital  tract. 

The  conditions  of  uterogestation,  parturition,  and  the  puerperium 
are  specially  perilous ;  hence  infection  of  the  puerperal  woman  is 
specially  destructive.  Decomposed  secretions  and  the  products  of 
fatty   degeneration    from    involution  and  from  the  menopause  favor 


INFECTIONS  OF  THE  REPRODUCTIVE  ORGANS.  167 

the  development  of  pathogenic  microbes.  Tumors,  displacements, 
tight  lacing,  and  constipation  are  among  the  common  local  predis- 
posing causes  of  morbid  congestion  and  consequently  of  infection  in 
the  pelvis.  Clearly  the  favoring  conditions  above  outlined  contribute 
to  the  preparation  of  the  soil  for  infection. 

2.  The  Exciting"  Causes  comprise  agents  that  have  the  power  to 
produce  and  to  maintain  morbid  irritation.  Greatly  preponderating, 
at  least  among  these,  are  the  pathogenic  microbes  and  their  products. 
The  extent  to  which  inflammation  may  be  produced  by  irritants  of 
non-bacterial  origin  without  the  presence  of  any  bacteria  whatever  is 
largely  a  laboratory  question,  and  is  not  fully  settled.  Among  the 
pathogenic  microbes  not  seldom  found  in  the  genitalia  are  the  staphy- 
lococci and  streptococci  of  suppuration,  bacillus  tuberculosis,  bacillus 
coli  communis,  and  the  pneumococcus  of  Frankel.  Bladder  para- 
sites and  the  saprophytes  from  the  rectum  and  colon  have  easy 
access  to  the  genitalia.  See  Chapter  II.,  on  Antiseptics  and  Ase])sis. 
The  bacillus  coli  communis  lives  in  acid  media,  and  can  thus  easily 
pass  through  the  acid  secretion  of  the  vagina  to  the  uterus. 

The  gonococcus  of  Neisser,  one  of  the  most  frequent,  destructive, 
and  insidious  factors  in  genito-urinary  infection,  is  discussed  partially 
elsewhere  in  connection  with  Vulvovaginitis,  Salpingitis,  and  Acute 
Metritis ;  its  chief  power  for  harm  lies  in  the  lasting  vitality  of  the 
germ  long  after  apparent  cure.  The  gonococcus  may  remain  inactive 
in  the  mucous  crypts,  liable  at  any  time,  even  while  quiescent  in  the 
individual,  to  be  communicated  to  another.  Hence  many  an  innocent 
and  previously  healthy  woman,  shortly  after  marriage  to  a  man  who 
supposed  himself  to  have  been  cured  of  gonorrhoea  years  before,  may 
by  contact  with  the  attenuated  virus  get  a  destructive  gonorrhoeal 
infection  of  the  genito-urinary  organs. 

Some  most  important  observations  upon  this  subject  have  been 
made  by  Wertheim.  A  direct  experiment  wdth  pure  culture  from  a 
gleety  discharge  of  two  years'  standing  gave  the  following  interesting 
results:  1.  Attempted  reinfection  of  the  original  urethra  with  this 
culture  was  always  a  failure.  2.  The  culture  when  transplanted  to  a 
coccus-free  urethra  produced  typical  acute  gonorrhoea.  3.  Infection 
from  this  back  again  to  the  original  urethra  gave  a  fresh  gonorrhoea, 
which  after  a  typical  acute  course  of  five  or  six  weeks  again  subsided 
into  a  chronic  gleet.  Thus,  by  passing  the  gonococci  through  another 
individual — that  is,  through  a  new  culture-ground — they  became  again 
virulent  to  the  urethra  which  was  invulnerable  to  them  before. 

This  explains  the  fact  that  an  apparently  healthy  subject  of  chronic 
gonorrhoea  may  infect  his  hitherto  uninfected  wife  and  become  again 
infected  from  her — /.  (?.,  the  gonococci  by  passing  through  the  new 
culture  of  the  wife  again  become  virulent  for  the  husband.  In  due 
time  each  becomes  tolerant  of  the  germ  ;  which,  however,  may  develop 
acute  infection  in  another  person.  The  common  notion  that  gonor- 
rhoea in  women  may  be  chronic  from  the  beginning  is  weakened  by 
the  experiments  of  Wertheim.  We  can  now  understand  why  the 
gonococcus,  even  after  years  of  apparent  cure,  may  regain  its  full 
virulence. 


168   INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

The  greatest  danger  of  gonorrhoea,  extension  to  the  Fallopian  tubes, 
will  be  considered  in  the  chapter  on  Salpingitis.  The  microbe  may 
be  found  in  the  uterus  and  tubes  long  after  it  has  disappeared  from  the 
vagina.  The  pavement  epithelium  of  the  vagina  and  the  acid  reaction 
of  the  fluid  normally  found  there  make  the  vagina  relatively  immune. 
The  crypts  of  the  uterine  and  tubal  mucosa  furnish  a  ready  resting- 
place  for  the  germ.  Even  here,  in  many  cases,  it  is  found  only  during 
the  exacerbations.  Menstruation  favors,  but  does  not  insure  its  revival. 
It  may  for  long  periods  remain  concealed  in  a  semiquiescent  state,  a 
destroyer  of  health,  a  menace  to  life.  The  frequency  of  chronic  gon- 
orrhoea— the  latent  gonorrhoea  of  Noeggerath — as  set  forth  in  various 
hospital  statistics  ranges  from  25  to  80  per  cent. ;  at  any  rate  the 
percentage  is  very  high. 

The  statistics  quoted  above  are  taken  from  clinics  largely  made  up 
of  prostitutes  and  semiprostitutes,  a  fact  which  necessarily  will  modify 
a  judicial  estimate  of  their  value.  It  is,  moreover,  essential  to  appre- 
ciate two  other  facts  :  first,  the  evidence  on  this  most  complicated  ques- 
tion, although  sufficient  to  lead  to  the  greatest  apprehension,  is  not  yet 
sufficient  to  establish  definite  and  undeniable  proof  on  the  extreme 
side  of  the  question ;  second,  many  excellent  clinical  observers  in 
private  practice  are  disposed,  on  the  whole,  to  qualify  the  danger  and 
to  conclude  that  it  is  vastly  overestimated.  If  the  questions  involved 
were  matters  only  of  scientific  interest,  their  solution  could  properly 
wait  for  further  and  more  exact  observation  ;  but  the  "  danger  and 
duty  of  the  hour  "  are  concerned  with  moral,  not  scientific,  problems, 
and  the  moral  obligations  are  serious  enough  to  lead  the  writer  to  pre- 
sent the  subject  even  from  the  ex  parte  standpoint. 

Why  do  large  numbers  of  apparently  healthy  young  women  date 
their  pelvic  infection  from  the  marriage-week  ?  Is  it,  as  one  author 
declares,  the  "  fatigue  and  excitement  of  the  wedding-journey  "  ?  Why 
do  so  many  women  with  perfectly  developed  reproductive  organs  re- 
main sterile  from  the  time  of  marriage  or  after  the  birth  of  a  single 
child  and  a  dangerous  "  childbed  fever  "?  The  causation  of  too  many 
such  cases  of  hopelessly  diseased  uteri,  tubes,  and  ovaries,  not  to 
mention  proctitis,  with  sometimes  rectal  stricture,  urethritis,  cystitis, 
pyelitis,  and  nephritis,  has  been  explained  by  the  word  idiopathic. 
The  histories,  if  written,  would  tell  often  of  an  apparently  cured 
gonorrhoea,  before  or  after  marriage,  in  the  husband.  If  the  most 
destructive  infection  may  follow  contact  with  a  subject  of  gonorrhoea 
after  the  discharge  has  ceased,  how  perilous  must  be  the  slight  gleety 
discharge  so  often  disregarded  !  Young  men  sometimes  are  advised 
to  marry  in  order  to  improve  their  sexual  hygiene,  and  so  to  cure  an 
intractable  chronic  but  "  innocent  gleet."  Such  advice  may  result  in 
the  destruction  of  the  reproductive  organs  of  an  innocent  woman.  It 
is  doubtless  possible,  perhaps  not  unusual,  for  gonorrhoea  to  be  so 
cured  that  the  individual  cannot  transmit  the  disease.  Failure,  how- 
ever, to  cultivate  the  gonococcus  from  the  urethral  secretions  does  not 
prove  its  absence.  So  long  as  it  can  be  cultivated  marriage  should  be 
prohibited.  In  every  suspected  case  marriage  should  be  deferred  at 
least  until  repeated  attempts  at  culture   have  failed.     A  gonorrhceal 


INFECTIONS  OF  THE  REPRODUCTIVE  ORGANS.  169 

record  does  not  necessarily  settle,  hut  it  always  complicates  the  question 
whether  the  individual  may  safely  marry. 

Pathology  and  Course  of  Infection  and  Inflammation. 

Bacterial  invasion  and  consequent  infection  may  spread  and  in- 
volve any  or  all  of  the  genito-urinary  organs  by  either  or  both  of 
two  routes  : 

1.  By  continuity  of  mucosa. 

2.  By  the  lymphatics  or  blood-vessels. 

1.  Infection  by  Continuity  of  Mucosa. — The  course  is  usually  up- 
ward from  the  vulva  or  vagina,  through  the  uterus  and  Fallopian  tubes 
to  the  ovaries  and  peritoneum,  or  through  the  urethra,  vagina,  blad- 
der, and  ureter  to  the  kidneys.  The  numerous  glands  of  the  vulva 
are  strongholds  where  the  infection  may  intrench  itself  and  whence  a 
constant  supply  may  find  its  way  to  the  organs  above. 

The  vagina,  advantageously  covered  with  pavement  epithelium,  is 
relatively  smooth,  like  skin,  and  is  supplied  with  an  acid  secretion. 
Bacteria,  accordingly,  find  lodgement  there  less  easily  than  in  the 
vulva.  Moreover,  the  acid  medium  unfavorable  to  the  growth  of 
about  90  per  cent,  of  all  pathogenic  microbes  makes  the  vagina  a 
barrier  difficult  to  pass. 

The  uterus,  although  protected  by  the  above  anatomical  and  physio- 
logical conditions  of  the  vagina,  is  itself  especially  vulnerable  on 
account  of  the  loose  arrangement  and  thinness  of  the  epithelial  cover- 
ing, the  villous  network  of  the  arbor  vitse  of  the  cervix,  the  confluence 
and  ramifications  of  the  glands,  and  the  richness  of  the  periglandular 
and  perivascular  network.  By  reason  of  these  conditions  the  cervix 
uteri  is  adapted  to  receive,  retain,  and  distribute  infection.  Were  it 
not  for  the  muscular  constriction  at  the  external  and  internal  ora  and 
the  uterotubal  constrictions  the  frequency  of  infection  of  the  endo- 
metrium would  be  much  greater. 

The  Fallopian  tubes  are  embryologically  and  anatomically  continu- 
ous with  the  uterus ;  they  are,  in  fact,  a  part  of  it,  and  subject  to  the 
same  causes  of  infection.  The  ovaries  and  pelvic  peritoneum,  in  direct 
communication  with  the  tubes,  may  receive  infection  from  below. 
Infection  by  continuity  of  mucosa,  however,  although  usually  from 
below,  does  not  alwavs  come  from  that  direction  ;  it  may  reach  the 
ovaries  and  pelvic  peritoneum  from  above,  and  descend  through  the 
tubes,  uterus,  and  vagina  to  the  vulva.  Tubercular  infection,  for 
example,  usually  goes  in  this  direction. 

2.  Infection  by  the  Lymphatics  and  Blood-vessels  is  undeniable 
in  puerperal  women.  The  traumatism  of  parturition,  often  very  ex- 
tensive all  the  way  from  the  uterus  to  the  vulva,  may  open  M'ide  the 
door  for  infection  to  be  transmitted  by  the  vessels.  The  destructive 
influence  of  the  infection — i.  e.,  phlebitis  and  lymphangitis — on  the 
vessels  themselves  may  impair  seriously  and  permanently  the  nutri- 
tion of  all  the  pelvic  organs. 

It  is  believed  commonly  that,  except  in  puerperal  cases,  infection 
travels  by  continuity  of  mucosa,  and  not  by  lymph-  and  blood-vessels 


170   INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

in  tlie  deeper  structures.  It  is  clear,  however,  that  since  infec- 
tion, as  is  proved  by  the  bubo,  often  is  transmitted  by  way  of  the 
lymph- vessels  to  the  inguinal  glands,  it  may  travel  also  by  way  of  the 
lymph-vessels  a  much  shorter  distance,  from  the  vagina  or  cervix  to 
the  parametria  and  Fallopian  tubes.  This  reasoning  by  analogy  has 
been  verified  by  experiment.  Some  observers,  notably  Lucas-Chara- 
pioniere/  maintain  that  this  is  the  more  common  mode  of  infection. 
VVertheim,  from  experimental  investigation  on  white  mice,  rabbits, 
dogs,  and  guinea-pigs,  concludes  that  gonococcus  infection  can  pass 
through  pavement  epithelium  and  connective  tissue  so  as  to  reach  the 
deeper  lymphatic  and  vascular  channels,  and  be  carried  by  them  from 
the  vagina  or  cervix  to  the  ovaries,  tubes,  and  peritoneum,  producing 
thus  ovaritis,  salpingitis,  and  peritonitis.  Giglio^  also  experimentally 
demonstrated  that  infection  may  travel  from  the  vagina,  cervix,  and 
bladder  to  the  broad  ligaments  and  may  produce  extratubal  pelvic 
abscess.  He  maintains  that  infection  by  the  vessels  is  more  frequent 
than  by  continuity  of  surface.  When  the  latter  occurs  he  asserts,  but 
without  proof,  that  it  is  more  commonly  in  the  descending  order  from 
the  tubes  to  the  uterus. 

Continuous  infection  does  not  always  mark  the  course  of  the 
microbes  through  the  vessels.  The  microbes  develop  at  the  points 
of  least  resistance ;  hence  the  tubes  may  suppurate  and  the  ligaments 
and  ovaries  go  free.  When,  however,  the  microbes  travel  by  way  of 
the  mucosa  a  continuous  inflammation  is  usual,  though  not  invariable. 

Infection  by  the  veins  is  especially  common  in  puerperal  cases.  It 
often  has  produced  general  septicaemia  and  pyaemia  through  very 
slight  lesions.  The  arteries  also  may  carry  infection.  This  is  proved 
by  the  fact  that  bacteria  have  been  found  in  places  where  they  must 
have  been  carried  by  the  centrifugal  circulation ;  for  example,  the 
gonococcus  in  the  knee-joint.'^  Hetero-infeetion  of  the  genitalia — 
z.  e.,  infection  from  Avithout — is  not  the  invariable  rule.  Diseased 
extrapelvic  organs  may  send  their  germs  by  way  of  the  lymphatics  or 
blood-vessels,  and  produce  secondary  infection  of  the  pelvic  ^^eri- 
toneum,  ovaries,  tubes,  and  other  genitalia.  Tubercular  infection  of 
the  tubes,  secondary  to  that  of  the  lungs,  is  a  familiar  example. 

Experiment  and  clinical  observation  also  show  that  both  puerperal 
and  non-puerperal  infection  may  travel  by  blood-vessels,  by  lymph- 
channels,  and  by  continuity  of  surface.  The  relative  frequency, 
however,  of  these  modes  of  transmission  is  a  matter  of  speculation. 
Probably  the  route  by  continuity  of  surface  is  really  a  superficial 
lymph-route — that  is,  the  infection  may  travel  along  the  lymph- 
channels  of  the  mucosa. 

Classification  of  Infection  and  Inflammation. 

Let  us  now  raise  a  question  relative  to  the  looseness  and  confusion 
of  the  current  classifications.     The  term  simple  infection  as  distin- 

1  Paris  Surgical  Society  Transactions,  December,  1888.  New  York  Medical  Journal,  March 
22,  1S90. 

-  Giglio.    Annalio  di  Obstetricia  e  Ginecologia,  Maj'  and  June,  1893. 
3  Luther.    Sammlung  kllnische  Vortriige,  1893. 


INFECTIONS   OF  THE  REPRODUCTIVE  ORGANS.  171 

guished  from  septic,  for  example,  has  no  strict  pathological  meaning. 
Is  the  so-called  simple  infection  aseptic  or  is  it  only  slightly  septic  ? 
We  know  that  an  infection  seemingly  very  mild  may  take  on  readily 
a  decidedly  virulent  character.  What  is  there  in  such  conditions  to 
designate  on  the  one  hand  as  simple,  on  the  other  as  septic  ?  In  the 
present  state  of  our  knowledge  we  must  use  for  descriptive  purposes 
an  adaptable,  and  therefore  flexible,  nomenclature.  In  this  nomen- 
clature words  like  simple  and  septic  can  have  only  a  loose  clinical 
significance.  They  cannot  be  utilized  as  the  outcome  of  scientific 
classification.  We  may  simplify  the  subject  by  throwing  out  such  a 
word  as  simple. 

A  distinction  between  acute  and  chronic  inflammation,  since  these 
conditions  enter  extensively  into  the  pathology  of  the  diseases  of 
women,  is  most  important.  Many  deny  altogether  the  existence,  for 
example,  of  chronic  inflammation  of  the  endometrium.  Some  attrib- 
ute the  condition  which  usually  is  classed  under  that  name  to  conges- 
tion ;  others  call  it  a  subinflammatory  state.  It  may  be  well  to 
remark  that  an  essential  factor  of  inflammation — round-cell  infiltra- 
tion— is  found  in  those  chronic  conditions,  and  that  they  may  therefore 
be  classed  properly  as  inflammatory ;  the  migration  of  white  cor- 
puscles, however,  occurs  more  slowly,  and  may  in  some  cases  be  very 
slight.  In  this  respect  the  difference  between  acute  and  chronic  in- 
flammation is  one  of  degree.  We  shall  avoid  the  question  whether 
certain  conditions  should  be  called  congestive,  inflammatory,  or  sub- 
inflammatory.  The  discussion  of  this  question  is  tiresome  and  un- 
profitable— a  contest  largely  of  words.  The  following  outline  of 
some  of  the  phenomena  of  inflammation  will  help  make  clear  the  dis- 
tinction between  acute  inflammation  and  the  conditions  which  usually 
are  grouped  under  the  name  chronic  inflammation. 

The  inflammatory  reaction  which  living  tissue  exhibits  to  morbid 
irritation  is  first  defensive,  and  then  constructive  or  reparative.  The 
defensive  process  is  an  effort  to  circumscribe  the  disease  by  throwing 
around  it  a  limited  wall  of  exudate  ;  the  morbid  force  thus  confined 
and  concentrated  within  narrow  limits  is  within  these  limits  more  or 
less  intense  and  destructive.  It  may  result  in  the  sacrifice  of  a  part 
for  the  safety  of  the  whole.  The  force  of  the  disease  is  spent  in  the 
destructive  process,  and  maybe  active  only  or  chiefly  within  the  limit- 
ing wall.  Finally,  normal  conditions  of  nutrition  are  re-established, 
the  constructive  or  reparative  process  becomes  active,  and  the  limiting 
wall  is  absorbed.  If  the  constructive  process  continues  until  re]iair  is 
complete  and  then  ceases,  the  part  will  resume  its  normal  functions — 
the  inflammation  will  be  at  an  end. 

Acute  Inflammation. — If  the  infection  is  of  such  virulence  or 
otherwise  of  such  character  as  to  call  forth  the  defensive  processes 
just  described,  and  to  produce  blood-stasis  with  more  or  less  severe 
swelling,  pain,  heat,  and  redness,  and  finally  to  produce  local  destruc- 
tion, the  inflammation  is  acute.  The  disease  may  terminate  with  reso- 
lution or  go  on  to  suppuration. 

Chronic  Inflammation. — If  the  irritation  is  of  minor  intensity, 
or  in  any  other  way  of  such  character  as  to   fall  short  of  provoking 


172  INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISOBDEBS. 

much  defensive  action,  there  will  be  little  or  no  limiting  wall,  and 
consequently  no  intense  destructive  process  concentrated  within  a  cir- 
cumscribed space  ;  heat,  swelling,  pain,  and  redness,  if  present,  will 
be  more  diffuse  and  less  pronounced.  Chronic  inflammation  occurs 
under  these  conditions — a  minimum  of  defence  and  an  excess  of 
construction. 

Chronic  inflammation  may  follow  acute  infection,  or  may  have  been 
subacute  or  chronic  in  the  beginning.  The  excessive  constructive  action 
which  belongs  to  it  explains  the  hyperplastic  and  hypertrophic  results 
of  so-called  chronic  metritis.  It  also  explains  certain  morbid  nutri- 
tive changes  in  the  blood-  and  lymph-vessels  of  the  pelvis  and  in  the 
cellular  tissue  of  the  pelvis.  Sclerotic  changes  in  other  orgaus,  such 
as  arterial  sclerosis  and  interstitial  nephritis,  offer  a  close  analogy. 

It  is  unprofitable  to  speculate  on  the  question  whether  the  condi- 
tions just  described  under  the  name  chronic  inflammation  may  better 
be  classified  as  congestive  or  as  subinflammatory  states.  They  are 
recognizable  under  either  of  these  names.  They  occur  more  fre- 
quently in  neuropathic  women,  and  especially  in  cases  of  the  various 
diatheses — anaemia,  lithsemia,  gout,  cholaemia.  They  are  usually  less 
dangerous  to  life  and  often  more  destructive  to  health  than  the  acute 
inflammations.  They  constitute  a  large  proportion  of  the  diseases 
of  women  and  include  some  of  the  most  distressing  ailments.  They 
are  persistent  and  hard,  often  impossible,  to  cure.  In  such  cases  it  is 
frequently  difficult  to  draw  the  lines  between  those  congestions  which 
fall  short  of  inflammation  and  actual  inflammation.  One  of  the  most 
common  forms  of  so-called  uterine  catarrh  is  that  which  occurs  in 
women  of  deficient  eliminative  poiver — that  is,  the  bowels,  kidneys, 
and  other  eliminative  organs  fail  sufficiently  to  throw  off  the  waste- 
products.  Under  these  conditions  the  mucous  glands  of  the  uterus, 
for  example,  whose  function  is  not  excretory,  may  undertake  vicari- 
ously to  make  good  the  deficiency.  An  unspeakable  amount  of  mis- 
directed  and  injurious  local  treatment  is  constantly  being  applied  to 
the  endometrium  in  such  cases. 

The  significance  of  pelvic  infection  varies  according  to  the  resist- 
ance of  the  patient,  to  the  location  and  nature  of  the  structures  in- 
volved, and  to  the  virulence  of  the  cause  which  produced  it.  Decided 
predisposing  causes  make  the  woman  less  able  to  resist  morbid  ir- 
ritation ;  and  infection  once  established  is  more  likely  to  be  severe 
and  progressive.  If  infection  is  confined  to  superficial  areas,  its  grav- 
ity is  relatively  much  less  than  Avhen  deeper  structures  are  diseased. 
Endometritis,  for  example,  is  less  serious  than  an  inflammation  in- 
volving the  uterine  wall  or  the  parametric  lymphatics  and  veins. 
Moreover,  the  same  kind  of  infection  may  be  more  serious  in  some 
places  than  in  others.  This  may  be  illustrated  by  the  case  of  a  man 
who  picked  his  teeth  with  a  vaccine  point  and  experienced  a  most 
distressing  result.  Some  bacteria  are  harmless  and  some  only  mildly 
virulent.  The  gonococcus  is  more  frequent,  and  therefore  more  dis- 
abling than  the  staphylococcus.  The  streptococcus  pyogenes  is  more 
dangerous  than  either. 

From  the  foregoing  it  is  easy  to  explain  why  an  infection,  even 


INFECTIONS  OF   THE  REPRODUCTIVE   ORGANS.  173 

in  the  deeper  structures,  may,  if  not  from  very  destructive  bacteria, 
present  in  the  more  acute  stages  most  of  the  subjective  and  some  of 
the  objective  appearances  of  a  fatal  disease,  and  yet  after  a  few  days 
terminate  in  complete  health.  The  reason  is  also  obvious  why  a  su- 
perficial vulvar  infection,  apparently  innocent,  may  be  the  result  of  a 
gonococcus  or  of  a  streptococcus  invasion,  and  may  by  continuity  of 
surface,  or  by  way  of  the  lymphatics  or  veins,  finally  destroy  life  or 
render  it  miserable  and  useless.  Some  organisms  may  excite  little 
or  no  defence — /.  e.,  may  not  attract  leucocytes — and  may  therefore 
sweep  through  the  system  with  rapidly  destructive  and  fatal  force. 
The  germ  of  tetanus,  for  example,  gives  rise  to  infection  but  does  not 
excite  defensive  inflammation. 

Diagnosis,  Prognosis,  and  Treatment  of  Infection  and 
Inflammation. 

The  symptoms  are  often  utterly  disproportionate  to  the  gravity 
of  the  lesions.  An  infection  of  little  danger  may  cause  the  greatest 
suffering ;  another,  which  directly  threatens  life,  may  be  almost  pain- 
less. Objective  examination,  therefore,  especially  in  acute  cases,  is 
important.  The  subjective  symptoms  may  be  misleading.  The  prog- 
nosis depends  upon  the  region  infected,  the  general  and  local  resist- 
ance of  the  patient,  and  the  extent  and  nature  of  the  infection. 

The  treatment  requires  the  individualization  of  each  case,  and 
the  reader  must  therefore  be  referred  to  the  special  subjects. 


CHAPTER   XI. 

VULVITIS,    VULVOVAGINITIS,   VAGINITIS. 

Infections  of  the  vulva  and  vagina  may  occnr  separately,  but 
they  commonly  appear  in  combined  form :  to  avoid  repetition  and  to 
simplify  the  subject  therefore  they  will  so  far  as  practicable  be 
described  together. 

The  importance  of  vulvitis  and  vulvovaginitis  commonly  is  under- 
estimated. Inflammation  seemingly  trivial  may  start  in  the  vulva  and 
rapidly  extend  to  all  the  reproductive  and  urinary  organs,  and  may, 
therefore,  give  rise  to  metritis,  salpingitis,  ovaritis,  peritonitis,  ure- 
thritis, cystitis,  pyelitis,  and  nephritis. 

The  external  genitals  are  tlie  labia  majora  and  minora  ;  the  clitoris, 
with  its  prepuce;  the  vestibule,  including  the  meatus  urinarius ;  the 
fossa  navicularis,  and  the  hymen.  The  hymen  separates  the  external 
genitals  from  the  vagina.  The  covering  of  the  external  genitals  is 
cutaneous,  although  it  partakes  somewhat  of  the  nature  of  mucous 
membrane. 

Definitions. 

Vulvitis  is  inflammation  of  the  external  genitals. 
Vaginitis  is  inflammation  of  the   nuicosa  and  submucosa  of  the 
vagina. 

Vulvovaginitis  is  inflammation  of  the  vulva  and  vagina. 

Classification. 

The  inflammation,  which  may  be  acute  or  chronic,  has  been  classified: 

1.  BacteriologicaUy ,  according  to  the  nature  of  the  bacterial  cause 

which  may  have  produced  it. 

2.  Anatomicalli/,  according  to  the  special  structures  involved. 

1.  Etiological  Classification. — The  following  inflammations  are 
of  bacterial  origin.  They  may  occur  as  vulvitis,  as  vaginitis,  or  as 
vulvovaginitis  : 

1.  Gonorrhoeal,  caused  by  the  gonococcus  of  Neisser. 

2.  Erysipelatous,  caused  by  the  streptococcus. 

3.  Diphtheritic,  caused  by  the  Klebs-Loffler  bacillus. 

4.  Tuberculous,  caused  by  the  tubercular  bacillus. 

5.  Mycotic,  caused  by  the  leptothrix  and  Oidium  albicans. 

6.  Syphilitic,  caused  by  the  bacillus  of  syphilis. 

7.  Chancroidal,  caused  by  Krefting's  bacillus. 

Other  forms  of  vulvovaginal  infection  are  caused  often  by  other 
micro-organisms,  chief  among  which  are  staphylococcus,  aureus, 
albus,  and  citreus,  and  the  unrecognized  micro-organisms  of  infectious 

174 


VULVITIS,    VULVOVAGINITIS,    VAGINITIS.  175 

and  contagious  diseases.  Pseudodiphtheric  vulvovaginitis  is  a  form 
in  which  a  false  membrane  is  developed,  but  is  not  due  to  the  bacillus 
of  diphtheria. 

Inasmuch  as  the  specific  micro-organism  seldom  is  recognized  at 
the  bedside,  the  above  classification  is  perhaps  more  important  from  a 
scientific  than  from  a  clinical  point  of  view. 

2.  Anatomical  Classification. — Vulvar  and  vaginal  inflammation 
may  attack  special  structures,  such  as  the  skin,  mucous  membrane, 
cellular  tissue,  glands,  and  follicles.  This  is  without  reference  to  the 
particular  nature  of  the  micro-organisms  which  may  have  been  the 
irritating  cause  of  the  infection — i.  e.,  the  anatomical  forms  may  come 
fn^m  bacteria  of  widely  different  natures  ;  these  forms,  which  may  occur 
singly  or  in  combination  with  one  another,  are  : 

Superficial  vulvovaginitis,  Paravaginitis, 

Senile  vulvovaginitis.  Follicular  vulvitis, 

Glandular  vulvitis,  Furuncular  vulvitis. 

A  peculiar  vaginal  disease  has  been  described  under  the  name 
emphysematous  vaginitis. 

The  classifications  above  outlined  cannot  from  the  clinical  stand- 
point always  be  followed.  An  effort,  however,  to  differentiate  between 
the  various  forms  should,  for  both  clinical  and  scientific  reasons,  be 
attempted. 

Eczema,  kraurosis  vulvae,  herpes  vulvae,  and  other  allied  disorders 
will  be  presented  in  the  following  chapters.  Pruritus  vulvae  and  vag- 
inismus, although  often  symptoms  of  vulvovaginal  inflammation,  are 
of  neuropathic  significance,  and  therefore  sometimes  are  classed  among 
the  gynecological  neuroses. 

The  general  consideration  of  vulvar  and  vaginal  inflammations 
includes  certain  factors  in  etiology,  pathology,  and  diagnosis  which 
are  more  or  less  common  to  all  varieties.  To  avoid  repetition  and  to 
give  a  general  impression  of  the  whole  subject,  these  factors  may  be 
studied  before  taking  tip  the  special  form. 

General  Consideration  of  Etiology. 

The  Favoring"  Conditions  which  predis])ose  to  inflammation  in 
general  have  been  outlined  in  Chapter  X.  Among  the  conditions 
which  specially  predispose  to  vulvovaginal  inflammation  are  the 
following : 

Filth,  Vaginal  fistulse. 

Obesity,  Excessive  coitus. 

Defective  nutrition.  Masturbation, 

Foreign  bodies,  such  Diabetic  and  other 
as  pessaries,  etc.,  irritating  urine. 

Exciting  Causes. — Numerous  bacteria,  some  of  whicli  have  been 
indicated  in  the  etiological  classification,  are  undoubtedly  the  essential 
causes  of  the  various  forms  of  vulvovaginal  inflammation. 


176    INFECTIONS,  INFLAMMATIONS,   AND  ALLIED  DISORDERS. 

Vulvovaginal  inflammation  is  occasionally,  and  especially  in  chil- 
dren, a  sequel  of  such  acute  infectious  diseases  as  diphtheria,  scarlatina, 
noma,  and  smallpox. 

The  Media  of  Infection  may  be  : 

Pathological  discharges  from  the  uterus,  Fallopian  tubes,  and 
vagina. 

Pelvic  abscesses  discharging  into  the  vagina. 

Urine  and  feces. 

Carcinomatous  discharges. 

Pediculi  pubis. 

The  disease  may,  especially  in  cases  of  severe  pruritus,  come  by 
extension  from  tlie  anus ;  very  often  the  morbid  irritation  is  furnished 
by  organisms  from  the  diseased  bladder,  ureters,  or  kidneys.  Infec- 
tion may  originate  in  the  vulva  or  from  the  surrounding  cutaneous 
surface.  It  may  result  from  direct  infection  or  from  an  irritating 
discharge  from  some  higher  zone  in  the  pelvis. 

Filth  outranks  every  other  cause,  with  the  possible  exception  of 
the  gonococcus. 

Epidemics  and  endemics  of  vulvitis  have  been  recorded. 

In  fat  women  of  sluggish  capillary  circulation  the  vulva  is  super- 
sensitive to  undue  irritation.  The  excessive  oily  secretions  undergo 
decomposition  into  fatty  acids,  which  cause  intense,  intractable  ery- 
thema of  the  vulva,  and  often  of  the  thighs  and  nates,  a  condition 
aggravated  by  filth — i.  e.,  by  accumulated  and  decomposed  secretions, 
especially  in  warm  weather,  when  perspiration  is  free.  Masturbation 
may  be  a  cause  or  a  result  of  the  disease. 

The  determining  factors  of  etiology,  especially  in  chronic  vulvo- 
vaginal infection,  lie,  first,  in  the  predisposition  of  the  patient ;  second, 
in  the  nature  of  the  infection  ;  third,  in  its  location.  Badly  nourished, 
neuropathic,  diathetic  women  are  predisposed  to  chronic  infection. 
Some  bacteria,  notably  the  gonococci,  are  especially  apt  to  produce 
intractable  infection.  A  principal  factor  in  the  chronicity  of  the  dis- 
ease is  the  intrenchment  of  the  bacteria  in  the  vulvar  glands  and 
follicles,  from  which  fresh  infections  may  travel  upward  to  the  vagina 
and  uterus.  In  the  same  way  bacteria  may  exist  in  the  muciparous 
glands  of  the  cervix  uteri,  and  from  this  point  be  distributed  not 
only  to  the  parametria,  corpus  uteri,  tubes,  peritoneum,  cellular  tissue, 
and  ovaries,  but  also  downward  to  the  vagina  and  vulva.  The  vulva 
and  the  cervix  uteri,  especially  the  latter,  are  two  great  distributing 
points  of  pelvic  infection. 

General  Considerations  of  Pathology  and  Pathological  Anatomy. 

Catarrhal,  suppurative,  hemorrliagic,  and  ulcerative  processes  are 
rather  phases  than  varieties  of  inflammation.  The  process  is  catarrhal 
when  the  product  is  a  pathological  increase  of  the  normal  secretion, 
suppurative  when  it  contains  pus,  hemorrhagic  when  it  contains  an 
appreciable  amount  of  blood — i.  e.,  when  the  destructive  process  has 
opened  the  walls  of  the  vessels — and  ulcerative  when  there  is  localized 
necrosis.  The  catarrhal  often  precedes  the  suppurative  infection  by  a 
distinct  period. 


VULVITIS,    VULVOVAGINITIS,    VAGINITIS. 


177 


The  skin  or  mucous  membrane  in  chronic  cases  usually  becomes 
thick  and  oedematous.  The  pyogenic  microbe  does  not  produce  sup- 
puration until  the  structures  are  impaired  in  a  degree.  A  circum- 
scribed suppurating  surface  may  be  surrounded  by  an  area  of  catarrhal 
inflammation.  The  necrotic  tendency  may  not  go  beyond  erosion  ;  it 
merely  may  impair  without  destroying  the  skin  or  mucosa,  or  it  may 
extend  far  below  the  surface  and  form  a  deep  ulcer.  Vulvitis  and 
vaginitis  may  exist  separately  or  together. 

So-called  granular  vuhovaghntis  is  due  to  swelling  and  hyper- 
trophy of  the  vulvovaginal  papillae,  is  found  chiefly  in  the  vaginaj  and, 

Figure  75. 


Granular  vaginitis.    Observe  the  purulent  secretion  on  the  posterior  vaginal  wall 


though  not  confined  to  that  period,  is  commonest  during  pregnancy. 
It  is  characterized  by  small,  round,  protuberant  granulations  scattered 
thickly  over  the  affected  surface. 

The  inflammation  may  result  in  extensive  ulceration  of  the  vulva 
or  vagina,  or  of  both.  Sufficient  plastic  material  may  be  thrown  out 
to  cause  adhesions  more  or  less  firm  between  the  nymphre  or  the  labia 
majora,  or  between  the  vaginal  walls,  or  between  the  vagina  and  the 
cervix  uteri.  Partial  or  complete  closure  of  the  vulva  by  adhe- 
sions is  not  uncommon  in  children.  Such  adhesions  usually  yield  to 
slight  force.  They  resemble  the  adhesions  sometimes  found  between 
the  prepuce  and  the  glans  penis  of  the  male  child ;  they  also  may 

12 


178    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

occur  between  the  clitoris  and  its  prepuce,  and  may  give  rise  to  serious 
nervous  disturbances.  Strong  adhesions  are  less  likely  to  occur  in  mar- 
ried women  than  in  virgins  and  aged  women  whose  organs  are  at  rest. 

Gonorrhoea  excepted,  suppuration  is  confined  mostly  to  the  vulvitis 
of  children,  especially  children  w^th  defective  nutrition.  The  purulent 
secretion  of  vulvitis  or  of  vaginitis  is  creamy,  abundant,  and  malodorous. 
Numerous  minute  points  of  superficial  suppuration  in  a  limited  area 
may  run  together  and  form  an  ulcer.  In  this  way  many  areas  of 
ulceration  may  be  formed.  If  ulcerative  changes  involve  the  small 
blood-vessels,  the  secretions  will  be  streaked  with  blood.  Severe 
cases  may  present  hemorrhagic  areas,  great  swelling,  and  even 
gangrene. 

Extension  of  vulvar  inflammation  to  the  vagina  is  common,  though 
not  so  common  as  it  would  be  were  it  net  for  the  following  anatomi- 
cal and  physiological  conditions  of  the  vagina  :  it  is  smooth,  and, 
being  covered  with  pavei^ent  epithelium,  closely  resembles  skin ;  is 
almost  if  not  quite  destituie  of  glands,  and  is  therefore  not  subject  to 
intense  catarrhal  affections. 

DSderlein  has  distinguished  microscopically  two  secretions  of  the 
vagina  :  one  the  normal  secretion,  a  whitish,  milky,  strongly  acid  dis- 
charge without  mucous  admixture  ;  the  other  a  pathological  secretion, 
yellowish,  faintly  acid,  often  neutral  or  alkaline,  sometimes  foamy 
and  mixed  with  mucus.  lu  the  normal  secretion  a  non-pathogenic 
vaginal  bacillus  was  found  constantly  present.  D5derlein's  experi- 
ments with  cultures  showed  that  this  bacillus  gives  to  the  normal 
secretion  its  acid  reaction,  which  is  due  to  lactic  acid.  These  normal 
vaginal  bacilli  were  found  to  be  unfavorable  to  the  growth  of  Staphy- 
lococcus pyogenes  aureus.  In  fact,  the  vast  majority  of  pathogenic 
bacteria  do  not  thrive  in  an  acid  medium.  In  the  pathological  secre- 
tion Ddderlein  found  the  pathogenic  bacteria  to  be  increased  and  the 
normal  vaginal  microbes  to  be  decreased.  The  abnormal  secretion 
usually  originates  in  the  cervix  uteri,  is  toxic  to  animals,  and  by  its 
hostility  to  the  normal  vaginal  microbes  decreases  or  neutralizes  the 
acidity  of  the  vaginal  secretion,  thereby  affording  a  favorable  culture- 
ground  in  the  vagina  for  pathogenic  bacteria. 

When  vaginitis  occurs,  the  desquamated  cells  of  vaginal  epithelium 
give  rise  to  a  thick,  pasty  accumulation  of  smegma  not  unlike  vernix 
caseosa.  AVhen  the  epithelium  is  shed  and  the  deeper  structure 
exposed,  pus  may  be  thrown  off"  from  the  exposed  surfaces. 

Vulvovaginitis,  if  superficial,  strongly  tends  to  recovery.  It  be- 
comes obstinate  when  the  vulvar  glands  already  described  are  in- 
volved, and  may  be  intractable  when  the  infection  reaches  the 
muciparous  glands  of  the  uterus.  Reference  is  made  to  the  remarks 
in  the  preceding  chapter  on  the  relative  capacities  of  the  vulva, 
vagina,  and  cervix  to  receive,  retain,  and  distribute  infection. 

General  Considerations  of  Symptoms  and  Diagnosis. 

The  purpose  of  a  diagnosis  is  not  so  much  to  give  a  name  to  the 
disease   as   to   furnish  a  basis   of    rational   treatment.     A  diagnosis 


VULVITIS,    VULVOVAGINITIS,    VAGINITIS.  179 

should  include,  therefore,  the  source,  variety,  and  complications  of 
the  disease.  It  would  be  absurd  to  confine  the  treatment  to  the  area 
of  inflammation  if,  for  example,  the  disease  were  secondary  to  metritis, 
carcinoma,  cystitis,  or  vaginal  fistula.  Attention  to  such  complica- 
tions as  fissure  in  ano,  hemorrhoids,  rigid  sphincter,  threadworms,  and 
endometritis  often  gives  relief.  The  diagnosis  should  have  special 
reference  to  the  possible  extension  of  the  disease  into  the  ducts  of 
the  vulvar  glands  and  urinary  organs.  The  discharge  from  a  pelvic 
abscess  has  been  mistaken  for  the  secretions  of  vulvovaginitis. 

The  symptom-group  in  acute  vulvovaginal  infiammation  comprises 
irritation,  pain,  redness,  swelling,  heat,  and  increased  secretion.  The 
systemic  symptoms  of  inflammation  are  absent  or  slight,  except  in 
cases  of  extensive  phlegmon  or  suppuration.  The  pain  and  swelling 
are  often  so  intense  that  the  patient  must  lie  down  with  the  thighs 
apart.  The  labia  minora  sometimes  swell  to  twice  the  size  of  the 
finger,  and  consequently  may  close  the  vulva ;  they  have  a  bright, 
glistening  appearance  not  unlike  the  inflamed  swollen  prepuce  of 
the  male.  The  pain  is  throbbing  and  extreme  in  proportion  to  the 
swelling.  The  inflamed  surfaces,  which  may  include  both  vulva  and 
vagina,  are  at  first  dry,  but  soon  become  moist  in  consequence  of  an 
effort  of  the  glands  to  relieve  the  congestion  by  increased  secretion. 
The  secretion,  usually  profuse,  is  a  chief  evidence  of  the  disease.  In 
children  the  disease,  unless  due  to  gonorrhoeal  infection,  is  confined 
usually  to  the  vulva.  Carcinomatous  ichor  causes  irritation  rather 
than  pain.  Frequent  difficult  and  painful  urination  are  common, 
especially  when  the  infection  has  extended  to  the  urethra  and 
bladder. 

Chronic  Vulvitis  and  Vaginitis  may  occur  separately  or  together. 
Clinically,  chronic  vulvitis  and  vaginitis  are  observed  more  commonly 
than  acute ;  they  may  follow  the  acute,  or  may  have  been  chronic  or 
subacute  in  the  beginning ;  they  are  recognized  by  their  persistence, 
by  their  tendency  to  recur  when  apparently  cured — see  Follicular  and 
Glandular  Vulvitis — and  sometimes  by  the  presence  of  erosion  of  the 
vulvar,  vaginal,  or  vulvovaginal  surfaces.  They  are  characterized  by  a 
scanty,  thin,  yellow  discharge,  usually  more  or  less  purulent ;  by  great 
local  irritation  ;  by  variable  redness  ;  by  slight  swelling,  and  some- 
times by  excessive  granulation.  The  surfaces,  especially  the  vulvar 
surfaces,  finally  become  hard,  oedeniatous,  leathery,  parchment-like, 
and  painful.  A  frequent  symptom  of  cnronic  vulvar  inflammation  is 
an  intolerable  pruritus,  characterized  by  intractable  itching  and 
burning.     See  Pruritus  vulvae. 

General  Considerations  of  Treatment. 

A  lesson  to  be  learned  from  the  above  observations  is  the  importance 
of  stamping  out  vulvar  inflammation,  and  thereby  preventing  its  inva- 
sion of  the  higher  zones  in  the  pelvis.  The  experiments  of  Doderlein 
M'ould  suggest  vaginal  douches  of  a  1  per  cent,  aqueous  solution  of 
lactic  acid.  This  would  clearly  not  apply  to  infection  from  bacteria 
which  grow  in  acid  media. 


180    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS 

The  vulva  is  normally  moist  from  its  own  secretions.  Dust  and 
dirt,  which  may  contain  irritants  capal)le  of  exciting  vulvitis,  easily 
reach  the  vulva  and  find  lodgement  there.  As  a  prophylaxis  against 
this  source  of  vulvitis,  and  as  a  better  protection  against  sudden 
changes  of  temperature,  the  closed  drawers  should  take  the  place  of 
the  commonly  worn  open  drawers.  The  daily  shower-bath  applied 
to  the  external  genitals  is  an  excellent  prophylaxis.  Strong  soap  is 
irritating,  and  therefore  injurious. 

The  Treatment  of  Acute  Vulvitis  is  chiefly  local,  and  includes 
two  essentials,  cleanliness  and  palliation.  Mild  alkaline  solutions, 
such  as  sodium  bicarbonate,  when  applied  to  the  vulva,  may  combine 
with  the  oily  secretion  to  form  a  soap  which,  upon  being  washed  oif 
with  warm  water,  leaves  the  surface  clean.  Washing  should  be  re- 
peated frequently  as  a  preparation  for  other  applications,  such  as  a 
lotion  of  equal  parts  of  dilute  solution  of  acetate  of  lead  and  fluid 
aqueous  extract  of  opium,  the  4  per  cent,  aqueous  solution  of  antipy- 
riue,  the  4  per  cent,  solution  of  cocaine,  the  4  per  cent,  ointment  of 
morphine  sulphate,  the  spray  of  an  alkaline  solution  or  of  the  5  per 
cent,  solution  of  carbolic  acid.  The  warm  sitz-bath  or  the  ice-bag 
applied  to  the  vulva  is  indicated  in  cases  of  extreme  irritation  and 
burning.  Absolute  rest  in  bed  is  important.  A  rectal  suppository 
containing  extract  of  opium,  two  grains,  and  extract  of  bella- 
donna, one-fourth  grain,  may  give  relief  and  secure  much-needed 
sleep.  Avoid  ointments  containing  animal  fat.  Vaseline,  clear 
or  stiifened  with  wax,  is  a  good  excipient.  If  the  labia  can  be 
separated  without  too  much  pain,  a  light  gauze  compress  saturated 
with  a  soothing  antiseptic  solution  may  be  placed  between 
them.  Buboes  and  other  abscesses  if  they  occur  should  be  opened. 
Great  care  is  needed  to  avoid  carrying  the  infection  from  the 
vulva  to  the  vagina  or  uterus  by  the  syringe-tube  or  examining- 
finger. 

The  general  treatment  consists  of  saline  purges,  and  soporifics 
and  anodynes  as  indicated  by  nervous  irritation  and  pain. 

The  Treatment  of  Chronic  Vulvitis  includes,  in  addition  to  such 
of  the  above  means  as  may  be  indicated,  astringents  and,  in  obstinate 
cases,  caustics.  Tiie  surfaces  should  be  dressed  with  gauze  comjiresses 
saturated  with  a  1  :  3000  aqueous  solution  of  the  bichloride  of  mer- 
cury, or  a  3  per  cent,  aqueous  solution  of  carbolic  acid.  If  the  dis- 
ease has  been  caused  by  Pediculi  pubis  or  other  parasites,  mercurial 
ointment,  in  addition  to  the  above  solutions,  should  be  used  to 
destroy  them.  One  of  the  most  effective  treatments  is  the  daily  pack- 
ing of  the  vagina  with  gauze  saturated  with  an  aqueous  solution  of 
argyrol,  5  per  cent. 

The  daily  hot-water  vaginal  douche  may  be  supplemented  with  a 
solution  of  copper  sulphate  or  zinc  sulphate,  one  drac^hm  to  the  quart 
of  water.  Extensive  erosion  of  the  skin  about  the  vulva  often  is 
cured  promptly  by  the  free  use  of  benzoated  oxide  of  zinc  ointment. 
Eroded  surfaces,  having  been  dried,  may  be  dusted  daily  with 
calomel  or  with  the  subgallate  of  liismuth.  In  neuropathic  cases  of 
severe  pruritus  almost  miraculous  relief  sometimes  follows  the  free 


VULVITIS,    VULVOVAGINITIS,    VAGINITIS.  181 

withdrawal  of  blood   from   the   uterus,  either  by  scarification  or  by 
leeches. 

Granular  vulvitis  should  be  treated  by  painting  the  granulated 
part  with  a  1  :  20  solution  of  nitrate  of  silver  and  daily  j^acking  the 
vagina  with  gauze.  Obstinate  cases  may  yield  to  frequent  applica- 
tions of  10  or  20  per  cent,  of  ichthyolate  of  ammonium  in  glycerin. 
The  application  is  made  best  with  a  compress  secured  by  a  bandage. 
The  treatment  of  vulvar  and  vaginal  infection  may  fail  until  a  causal 
or  complicating  endometritis  has  been  cured. 

SPECIAL   FORMS    OF    VULVOVAGINAL   INFLAMMATION. 

The  special  forms  of  vulvovaginal  inflammation  will  be  considered 
separately  in  the  following  paragraphs. 

GonorrhcBal  Vulvovaginitis. 

Gonorrhoea,  one  of  the  most  active  and  most  destructive  infections 
in  the  reproductive  organs,  is  always  the  result  of  gonococcus  infection. 
The  disease  is  characterized  by  a  strong  tendency  to  penetrate  and 
spread,  and  is  prone  to  attack  the  follicles  and  glandular  structures 
of  the  vulva,  especially  the  vulvovaginal  glands  and  Skene's  glands. 
Diffuse  and  deep  cellular  inflammation  and  abscess  of  the  vulva  may 
also  result  from  gonococcus  infection.  See  remarks  on  the  gonococ- 
cus and  recurrent  gonorrhoea  in  woman  in  Chapter  X.,  and  Urethritis 
in  Chapter  XXIV. 

The  infection  not  uncommonly  extends  throughout  the  genito- 
urinary tract,  although  the  constant  downward  current  of  urine  may 
protect  in  a  measure  the  more  distant  urinary  organs.  If  the  disease 
originates  in  the  vulva,  it  usually  extends  to  the  vagina,  and  vice 
versa.  The  urethra  seldom  escapes.  The  inguinal  glands  may  be 
infected  through  the  lymphatics,  and  are  then  especially  prone  to 
suppuration. 

Children  are  more  subject  to  this  infection  than  generally  is  sup- 
posed. It  may  come  from  infected  bed-linen,  from  bathing  with 
infected  cloths  or  sponges,  or  from  the  unclean  hands  of  infected 
nurses.  In  children  the  disease  is  less  liable  than  in  adults  to  extend 
to  the  vagina,  because  the  vagina  is  protected  in  a  measure  by  the 
hymen.  It  may,  however,  easily  be  carried  upward  on  the  douche 
point. 

Diagnosis. — A  suspicious  exposure,  great  pain,  and  unusual  sys- 
temic disturbance  should  excite  suspicion.  Radiation  of  pain  to  the 
rectum,  perineum,  and  bladder,  burning  in  the  urethra,  and  involve- 
ment of  the  vulvar  glands  are  strong  diagnostic  signs.  The  positive 
diagnosis  depends  upon  finding  the  gonococcus  by  microscopical 
examination  of  the  secretion. 

Treatment. — It  is  highly  important  to  stamp  out  the  gonorrhoeal 
infection  while  it  is  yet  in  the  vulva  or  vagina,  and  thereby  to  keep 
the  infection  from  going  to  the  higher  zones  of  the  genito-urinary 
system.     Daily  packing  of  the  vagina  loosely  with  tampons  of  sterile 


182    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

gauze  or  absorbent  cotton  saturated  with  an  aqueous  solution  of 
formalin,  1  :  1000,  will  be  useful  during  the  active  stage.  Let 
the  vulvovaginal  surfaces  be  painted  once  or  twice,  as  in  granular 
vulvitis,  with  a  solution  of  nitrate  of  silver,  1  :  20,  and  packed  with 
dry  sublimated  or  borated  gauze,  which  should  be  renewed  as  often 
as  it  becomes  moist  from  the  secretions.  At  each  time  of  changing 
the  gauze  the  surfaces  should  be  cleansed  thoroughly  with  a  warm 
5  per  cent,  aqueous  solution  of  carbolic  acid  ;  this  is  to  be  followed  by 
a  thorough  washing  with  peroxide  of  hydrogen,  which  is  very  cleans- 
ing to  the  deeper  glandular  structures. 

A  solution  of  nitrate  of  silver  may  be  used  with  excellent  effect  as 
follows :  The  patient  being  in  the  dorsal  position,  with  the  hips 
elevated,  introduce  a  cylindrical  speculum  so  as  to  expose  the  cervix 
uteri  and  vault  of  the  vagina.  Into  this  speculum  pour  a  3  per  cent, 
aqueous  solution  of  nitrate  of  silver.  Allow  this  solution  to  bathe  the 
cervix  uteri  and  vault  of  the  vagina  for  five  minutes;  then  remove  the 
solution  by  means  of  absorbent  cotton.  This  treatment  should  be 
repeated  two  or  three  times  a  week.  Argyrol  may  be  substituted 
advantageously  for  the  silver  nitrate. 

The  diet  should  be  non-irritating.  Urethral  or  bladder  complica- 
tions call  for  diuretic  drinks.  Crayons  of  ichthyol  in  the  urethra,  if 
tolerated,  may  be  useful. 

Erysipelatous  Vulvovaginitis. 

Erysipelas  is  primarily  an  inflammation  of  the  lymphatic  vessels 
of  the  skin  or  mucous  membrane.  The  infection  is  caused  by  a  strep- 
tococcus similar  to  the  streptococcus  pyogenes — perhaps  identical  with 
it.  The  disease  is  febrile,  always  acute,  often  suppurative  and  super- 
ficial, and  chiefly  characterized  by  a  tendency  to  spread.  There  are 
three  varieties  :  the  erythematous,  the  vesicular,  and  the  gangrenous. 

The  Erythematous  erysipelas  of  the  vulva  and  vagina  is  the 
mildest  form.  It  presents  redness  and  heat  of  the  surface.  The  skin 
or  mucous  membrane  is  but  little  swollen,  and  the  tendency  is  strongly 
toward  spontaneous  recovery. 

The  Vesicular  form  is  more  severe,  is  characterized  by  intense 
inflammation  of  the  skin  or  mucous  membrane,  by  marked  oedema, 
and  by  the  appearance,  under  the  surface,  of  vesicles  or  bullae,  which, 
like  blisters,  contain  serum.  Finally,  infection  in  these  vesicles  may 
cause  suppuration,  and  the  inflammation  may  extend  to  the  deeper 
structures  and  become  phlegmonous. 

The  Gangrenous  is  the  most  dangerous  form  of  erysipelatous 
vulvitis.  It  apparently  results  from  rapid  development  of  strep- 
tococci and  their  products  in  the  lymph-channels  and  connective- 
tissue  spaces  so  as  to  shut  oft'  nutrition  and  cause  necrosis.  It 
destroys  large  areas  or  small  patches  of  skin  or  mucous  membrane 
and  sometimes  deeper  structures. 

Erysipelatous  vulvovaginal  inflammation  occurs  not  infrequently 
in  very  young  infants  by  extension  from  the  navel,  or  it  may  spread 
from  the  vulva  to  the   thighs  and  nates ;  it  is  observed  sometimes  in 


VULVITIS,    VULVOVAGINITIS,    VAGINITIS.  183 

childhood,  but  is  rare  in  adults,  except  in  childbed,  where  it  is  a  most 
dangerous  affection.  Bad  nutrition  and  filth  are  strong  predisposing 
causes.  Generally  speaking,  the  prognosis  is  favorable,  doubtful,  or 
grave  according  to  the  extent  and  severity  of  the  disease.  Gangrene 
of  the  vulva,  especially  in  infants,  is  almost  ahvays  fatal. 

Treatment  does  not  diifer  materially  from  that  of  the  diphtheritic 
form  ;  see  below.  If  the  inflammation  become  phlegmonous  and  re- 
sult in  suppuration,  the  abscess  should  be  opened.  The  gangrenous 
variety  calls  for  strong  supporting  measures  and  rigid  disinfection 
with  pure  carbolic  acid. 

Diphtheritic  Vulvovaginitis. 

This  form  of  vulvovaginal  inflammation  rarely  appears  in  the  non- 
puerperal adult.  It  is  sometimes  the  local  manifestation  of  a  very 
grave  form  of  puerperal  fever  which  occurs  in  epidemics,  especially 
in  the  obstetrical  wards  of  hospitals.  It  sometimes  attacks  children 
during  epidemics  of  ordinary  diphtheria. 

There  are  other  forms  of  membranous  vulvovaginitis  in  which 
the  germ  of  diphtheria  is  not  present — pseudodiphtheric  vulvo- 
vaginitis. 

Treatment.— The  general  treatment  includes  energetic  supporting 
measures,  such  as  quinine,  the  mineral  acids,  ferric  chloride,  and 
sometimes  heart  stimulants.  The  bowels  should  be  regulated,  if  nec- 
essary, by  mercurials  and  salines.  The  local  treatment  is  the  same 
as  in  the  general  therapeutics  of  vulvovaginitis:  antitoxin  and  other 
measures  are  indicated  as  for  diphtheria  elsewhere. 

Tubercular  Vulvovaginitis — Lupus. 

Tubercular  inflammation  has  been  found  in  every  part  of  the 
genital  tract,  the  order  of  frequency  for  the  various  parts  being 
the  Fallopian  tubes,  corpus  uteri,  ovaries,  vagina,  cervix  uteri,  and 
vulva.  It  gives  no  characteristic  symptoms ;  the  diagnosis  depends 
upon  finding  the  bacillus  tuberculosis.  The  disease  may  be  secondary 
to  tuberculosis  in  some  extrapelvic  organ,  or  may  be  primary  in  the 
genitals. 

Tubercular  vulvitis,  commonly  called  lupus,  which  sometimes  is 
described  as  a  neoplasm,  is  rare  and  confined  chiefly  to  the  period  of 
maturity.  The  characteristic  lesion  is  the  formation  of  tubercles  and 
nodules,  which  undergo  cheesy  or  colloid  degeneration,  and  finally 
ulceration  and  cicatrization  with  much  increase  of  connective  tissue 
throughout  the  affected  area.  The  ulcer  is  of  red  color,  with  a  granu- 
lar base,  is  purulent  and  prone  to  bleed.  It  may  be  superficial  or  so 
deep  as  to  make  permanent  fistulte  between  the  bladder,  vagina,  and 
rectum.  The  cicatricial  contraction  which  follows  the  ulceration 
may  result  even  in  strictures  of  the  urethra,  vagina,  or  rectum. 
Hypertrophic  processes  may  or  may  not  be  associated  with  ulceration. 
The  general  thickening  and  induration  of  the  aflFected  part  may  lie 
so  extensive  as  to  give  the  labia  the  appearance  of  elephantiasis.     The 


184    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

vulva  and  periueum  become  studded  with  nodules  of  red  or  violet 
color.  Great  chronicity  and  little  pain  are  notable  characteristics  of 
the  disease.  The  general  health  may  continue  unimpaired  for  many 
years. 

The  Treatment  of  tubercular  vulvovaginitis  is  the  same  as  that 
of  tubercular  disease  elsewhere — L  e.,  systemic  and  local.  Proper 
climate,  outdoor  life,  careful  attention  to  nutrition,  and  thorough 
cauterization.  Early  excision  of  the  diseased  part  together  with  a 
layer  of  healthy  tissue  around  it  gives  good  promise  of  radical  cure. 
The  a;-rays  have  given  some  apparent  success  but  the  time  has  not 
arrived  for  a  positive  statement  as  to  the  value  of  this  treatment. 


Mycotic  Vulvovaginitis. 

Etiology. — Mycotic  vulvovaginitis  is  most  common  in  diabetic 
subjects ;  certain  fungi— mycoses — chief  among  them  the  leptothrix, 
o'idium  albicans,  and  leptomitus,  often  are  found  in  the  vulvar  secre- 
tions, and  are  doubtless  the  exciting  cause.  Diabetic  urine  appar- 
ently favors  the  development  of  the  fungi,  although  the  disease  is  not 
always  associated  with  sugar  in  the  urine.  Furunculosis  often  com- 
plicates diabetic  vulvitis. 

Catarrh  of  the  genital  tract  and  pregnancy  are  predisposing  causes. 
The  micro-organism  may  be  brought  in  contact  with  the  genitals  by 
intercourse,  especially  with  a  diabetic  man.  The  fungus  may  be 
carried  on  the  finger  of  the  examiner.  Winckel  cites  two  cases  in 
which  the  infection  apparently  was  traced  to  the  touching  of  the  gen- 
itals by  the  iiand  dusted  with  flour. 

Symptoms. — The  swelling  of  the  vagina  may  extend  to  the  vulva, 
and  then  be  so  great  that  the  patient  cannot  stand  nor  walk.  The 
epithelium  may  be  exfoliated  and  the  urine  cause  pain  when  in  con- 
tact with  the  exposed  surfaces.  The  pruritus  may  be  extreme  and 
paroxysmal  or  continuous.  The  depressing  influence  of  the  hyper- 
secretion, sleeplessness,  pain,  and  loss  of  appetite,  are  apt  to  hasten 
the  fatal  result  of  a  complicating  diabetes.  The  vulva  throughout 
has  a  coppery-red  color,  is  much  swollen,  is  dry  in  some  parts 
and  may  be  moist  in  others.  Scratching  may  cause  here  and  there 
considerable  bleeding.  The  skin  is  dry  and  brittle,  wrinkled  and 
rigid.  The  affection  may  invade  the  inner  folds  of  the  nymphse,  the 
meatus  urinarius,  the  folds  of  the  groin,  the  mons  veneris,  and  the 
folds  of  the  nates,  and  may  surround  the  anus.  An  improvement  in 
the  general  condition  of  the  patient  may  lessen  the  local  disease, 
which  is  liable  to  return,  however,  with  increased  severity.^ 

Diagnosis. — Small  yellow  or  white  spots  upon  the  reddened  mucous 
membrane  or  skin,  which  cannot  be  scraped  off  without  at  the  same 
time  removing  the  epithelium,  are  characteristic  of  the  disease. 
These  spots,  taken  together  with  finding  the  micro-organism  by 
microscopical  examination,  will  establish  the  diagnosis. 

Prognosis. — The  prognosis  is  variable.     The  disease  may  be  most 

«  Winckel.    Diseases  of  Women. 


VULVITIS,    VULVOVAGINITIS,    VAGINITIS.  185 

persistent  or  may  disappear  under  treatment.  In  pregnant  women  it 
may  disappear  after  delivery. 

Treatment. — If  there  is  an  associated  diabetes,  a  diabetic  dietary, 
in  addition  to  tonics  and  mild  saline  laxatives,  i^s  indicated  first.  The 
intolerable  itching  and  burning  necessitate  local  remedies,  of  which 
many  have  been  used  with  varying  and  temporary  success.  /S^^ash 
thoroughly  with  a  tepid  solution  of  corrosive  sublimate,  1  :  2000,  or 
with  a  saturated  solution  of  boric  acid.  Benzoated  oxide  of  zinc 
ointment,  or  an  ointment  of  vaseline  and  salicylic  acid,  1  :  200,  is  use- 
ful. The  sitz-bath,  temperature  80"  F.,  prolonged  for  an  hour,  often 
gives  relief;  to  this  bath  may  be  added  a  pound  of  Indian  meal. 
Astringent  washes,  for  example,  of  tannin  or  alum,  or  sulphate  of 
zinc,  may  be  indicated. 

Since  the  skin  in  mycotic  vulvitis  is  already  dry  and  brittle,  it  is 
not  well  to  dust  the  vulva  with  powder.  To  relieve  the  suffering, 
which  is  usually  worse  at  night,  place  on  the  parts  at  bedtime  a  com- 
press moistened  with  a  3  per  cent,  solution  of  carbolic  acid. 

Anodynes  may  be  used  locally  ;  one  part  of  chloroform  to  five 
parts  of  almond  oil.  ointments  of  belladonna  and  morphine,  or  a  6 
per  cent,  solution  or  ointment  of  cocaine,  may  give  temporary  relief. 
The  disease  in  a  diabetic  subject  is  usually  intractable  or  incurable. 
See  Furuncular  Vulvitis  and  Pruritus  Vulvae.  A  most  eifective 
application  is  an  ointment  containing  :  camphor,  4  grains ;  chloral 
hydrate,  4  grains ;  menthol,  ^  grain  ;  carbolic  acid,  1  grain  ;  lanolin, 
100  grains. 

Mycoses  of  the  vulva  and  vagina  in  subjects  not  suffering  from 
diabetes  are  usually  self-limited  or  easily  cured  by  the  treatment 
above  indicated.  The  vaginal  mycoses  require  douches  of  carbolic 
acid,  3  per  cent.,  or  of  corrosive  sublimate  solution,  1  :  2000. 

Syphilitic  Vulvovaginitis  and  Chancroid. 

The  subject  includes  the  primary,  secondary,  and  tertiary  forms 
of  syphilis. 

Chancre  develops  after  an  incubation  of  from  ten  to  twenty  days, 
usually  the  latter.  It  is  first  a  reddened  excoriated  spot  or  a  hard- 
ened papule  with  or  without  ulceration.  The  characteristic  feature  is 
induration.  The  induration  may  be  parchment-like  and  superficial, 
or  it  may  be  deep  and  reach  laterally  far  beyond  the  edge  of  the  ero- 
sion or  ulceration.  The  indurated  tissue  is  hard,  like  cartilage,  but 
seldom  so  pronounced  in  women  as  in  men.  In  the  ulcerative  form 
the  ulcer  is  usually  small  and  funnel-shaped,  with  sloping  edges, 
superficial  or  deep  ;  the  edges  are  never  undermined.  The  bottom 
of  the  ulcer  is  gray,  the  discharge  seropurulent  and  never  free. 
Rarely  more  than  one  chancre  ever  appears  in  the  same  person.  The 
inguinal  glands  usually  enlarge,  but  except  in  cases  of  mixed  infec- 
tions do  not  suppurate.  Chancre  is  only  the  local  sign  of  syphilis, 
and  its  pus  is  rarely,  if  ever,   auto-inoculable. 

The  Secondary  and  Tertiary  Lesions  of  Syphilis  include  mucous 
patches  and  gummata.     These  patches  on  the  genitals  have  the  same 


186    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

general  character  as  when  they  appear  elsewliere.  In  the  second 
stage  flat  condylomata  form.     See  Chapter  XXV. 

Chancroid,  which  is  a  purely  local  infection,  has  no  period  of  in- 
cubation, is  auto-inoculable,  has  a  rounded  or  oval  margin,  abrupt 
or  ragged  edges,  no  induration,  and  may  develop  into  a  large  or 
phagedenic  ulcer.  The  inguinal  glands  are  prone  to  suppurate.  Large 
numbers  of  chancroids  may  occur  on  the  same  person. 

Treatment. — The  treatment  is  that  of  syphilis  or,  as  the  case  may 
be,  chancroid.  The  local  lesions  may  be  complicated  with  other  forms 
of  vulvovaginitis,  which  should  have  special  attention  according  to 
their  class. 

Superficial  Vulvitis  and  Vaginitis. 

This  sometimes  is  called  simple  inflammation.  When  acute  it 
often  produces  mild  systemic  fever  and  sometimes  excessive  swelling, 
pain,  and  irritation.  The  disorder  is  erythematous  and  resembles 
urticaria.  It  does  not  give  rise  to  much  exudate,  is  not  very  virulent, 
and  seldom  or  never  extends  to  the  follicular  or  glandular  elements  or 
to  the  uterus.  It  tends  to  I'apid  resolution  on  removal  of  the  irritat- 
ing cause.  It  often  causes  excessive  oedema  of  the  labia  minora, 
wdiich  oedema  may  disappear  in  a  few  hours. 

The  causes  of  superficial  vulvitis  and  vaginitis  are  often  largely 
mechanical,  such  as  masturbation,  excessive  coitus,  rubbing,  scratch- 
ing. Pinworms,  taenia  circinata,  and  irritating  vaginal  or  uterine 
discharges  are  among  the  other  causes.  The  inflammation  may  be 
in  the  form  of  vulvitis,  vulvovaginitis,  or  vaginitis.  It  does  not  in- 
volve the  corium  in  the  vulva  nor  the  submucosa  in  the  vagina.  The 
treatment  has  been  described  in  the  general  therapeutics  of  vulvo- 
vaginal inflammation. 

Senile  Vulvovaginitis. 

Senile  vulvovaginitis  is  usually,  though  not  always,  a  somewhat 
deep  inflammation.  The  retrogressive  physiological  processes  of  the 
menopause  which  result  in  senile  atrophy  of  the  reproductive  organs 
destroy  in  great  part  the  epithelial  portion  of  the  mucous  membrane 
of  the  uterus,  vagina,  and  vulva,  so  that  this  membrane  becomes  com- 
posed largely  of  fibrous  tissue.  This  fibrous  tissue  when  inflamed  is 
prone  to  granulate,  to  suppurate,  to  cicatrize,  to  contract,  and  to  form 
adhesions  of  any  surfaces  in  contact  Avith  one  another.  Stenosis  at  the 
internal  or  external  os  uteri  may  prevent  free  drainage  of  the  uterine 
secretions.  These  secretions,  already  pathological,  when  retained 
l)ecome  excessively  irritating.  Similar  secretions  also  come  from  the 
vagina  and  vulva.  Aged  women,  therefore,  who  have  long  passed 
the  menopause,  are  subject  to  a  most  irritating  vulvovaginitis — a  most 
exhausting  and  distressing  pruritus  vulvse.  The  adhesions  often 
entirely  envelop  the  vaginal  portion  of  the  cervix  and  may  obliterate 
partially  the  vagina.  The  vulvar  glands  and  mucous  crypts,  especi- 
ally in  pruritus  cases,  are  involved  extensivelv.     Removal  of  them 


VULVITIS,    VULVOVAGINITIS,    VAGINITIS.  187 

is  the  only  means  of  relief  from  the  intolerable  itching  and  burning. 
See  Treatment  of  Glandular  Vulvitis,  below.  In  other  respects  the 
treatment  is  the  same  as  that  laid  down  in  the  general  therapeutics 
of  vulvovaginal  inflammation. 

Glandular   Vulvitis. 

Inflammation  of  the  Urethral  Cysts. — Five  or  six  small  race- 
mose glands  are  situated  around  the  meatus.  They  have  short  ducts 
with  wide  openings  ;  two  of  them  are  in  little  depressions  on  either 
side  of  the  meatus.  Inflammation  in  these  glands  or  crypts,  not  un- 
common during  and  after  the  menopause,  may  cause  a  most  persistent 
pruritus  with  extreme  itching  and  burning ;  this  occurs  most  fre- 
quently in  connection  with  senile  vulvitis. 

!  Inflammation  of  the  Vulvovaginal  Glands. — The  vulvovaginal 
glands  of  Bartholin  are  on  either  side  of  the  vaginal  orifice  near  the 
posterior  extremity  of  the  bulb  of  the  vagina.  Their  ducts  are  about 
one-half  inch  long  and  open  into  the  fossa  navicularis,  where  they  are 
seen  easily. 

Inflammation  of  these  glands  comes  by  extension  from  the  external 
surface.  The  glands,  or  their  afferent  ducts,  or  both,  may  be  involved. 
A  suppurating  gland  may  pour  out  pus  through  the  duct ;  or  the  duct 
may  close  by  adhesive  inflammation  and  form  an  abscess  ;  it  may 
become  occluded  and  distended  with  the  normal  secretion  of  the  gland, 
and  thus  form  a  retention-cyst.  One  or  both  glands  may  be  affected. 
The  disease  is  very  common.  Sanger  describes  a  red  areola  (macule) 
about  the  openings  of  the  ducts  as  an  evidence  of  gonorrhoea. 

Diagnosis. — Abscess  is  distinguished  from  retention-cyst  of  the 
glands  by  the  presence  of  acute  pain  and  heat  in  the  former  and  the 
absence  of  them  in  the  latter.  Enlargement  of  the  gland  under  either 
of  these  conditions  is  distinguished  from  phlegmonous  vulvitis  by 
the  location  of  the  former,  which  corresponds  to  that  of  the  gland, 
while  phlegmon  may  be  anywhere  in  the  vulva ;  and  from  hernia  by 
the  absence  of  the  characteristic  signs  of  hernia  and  by  the  location. 
See  Figs.  76  and  79. 

Glandular  vulvitis,  once  established,  becomes  chronic.  The  glands 
serve  as  culture-ground  for  the  infecting  bacteria,  hence  superficial 
vulvovaginitis,  though  apparently  cured,  may  recur  again  and  again 
from  the  infected  glands.  The  vulva,  through  its  glandular  struct- 
ures, is  a  great  distributing  point  of  pelvic  infection.  The  periodical 
congestion  of  menstruation  is  a  recognized  predisposing  cause  of  re- 
curring pelvic  inflammation.  As  stated  elsewhere,  the  capacity  of 
glandular  structures  to  receive,  .retain,  and  distribute  infection  often 
will  explain  the  frequently  observed  attacks  of  recurrent  gonor- 
rhoea in  women. 

The  explanation  of  so-called  latent  gonorrhoea  in  the  male,  dis- 
cussed by  Noeggerath,  is  the  same  as  that  given  in  the  preceding  para- 
graph for  recurrent  gonorrhoea  in  women. 

The  Treatment  of  G-landular  Vulvitis,  when  acute  and  non-sup])ura- 
tive,  is  palliation  and  cleanliness,  the  latter  to  be  secured  chiefly  by 


188    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 


disinfectants.      When  the  inflammation  is  chronic^  the  treatment  varies 
with  the  different  glands,  as  follows  : 


Figure  76. 


Figure  77. 


Figure  78. 


Figure  79. 


K.. 

_^ 

'A 

1   ' 

'^ 

P? 

> 

fi  <  { 

Figure  76.— Enlarceuient  of  the  vulvovaginal  gland  by  cyst :  an  abscess  would  have  a  similar 
appearance,  but  jmUke  the  cyst  would  be  painful  on  pressure. 

Figure  77.— Cyst  wall  dissected  out ;  wound  held  open  by  tenacula;  introduction  of  first 
suture  for  closure  of  the  wound;  silkworm  gut  suture;  a  small  tubal  or  gauze-wick  drain  is 
useful  in  these  cases. 

Figure  78.— Wound  closed  with  fine  silkworm  gut  sutures. 

Figure  79. — Right  inguinal  hernia  simulating  vulvovaginal  cyst  or  abscess. 

The  five  or  six  small  mucous  crypts  near  the  meatus  urinarius, 
when  infected,  are  the  seat  of  an  intolerable  pruritus.     The  treatment 


VULVITIS,    VULVOVAGINITIS,    VAGINITIS. 


189 


is  to  destroy  the  glands  by  the  actual  cautery  or  to  remove  them  by 
excision.  The  author's  preference  is  to  excise  them,  close  the  wounds 
by  suture,  and  secure  union  by  first  intention. 

The  treatment  of  abscess  of  a  vulvovaginal  gland  is  the  same  in 
principle  as  for  abscess  elsewhere ;  it  should  be  opened  \^idely,  the  wound 
packed  with  gauze,  and  made  to  heal  from  the  bottom  by  granulation. 
In  opening  the  abscess  find  the  gland,  if  possible,  and  remove  it. 

When  a  retention-cyst  has  formed  from  occlusion  of  the  duct,  the 
sac  should  be  dissected  out,  the  wound  sutured,  and  for  one  or  two 
days  drained  with  a  small  rubber  tube  or  with  gauze  wick.  If  drain- 
age is  not  used,  the  wound  is  liable  to  suppurate. 

Sometimes  chronic  suppuration  of  the  gland  occurs  through  the 
open  duct.  Then  the  duct  should  be  incised  widely,  the  gland 
removed,  and  the  wound  packed  with  gauze. 

Follicular  Vulvitis. 

The  labia  minora  and  raajora  are  supplied  abundantly  with  hair- 
bulbs,  sebaceous  follicles,  and  sweat-follicles.     Inflammation  in  these 

Figure  80. 


Follicular  vulvitis. 


structures  of  an  acne-like  character  is  follicular  vulvitis  or  folliculitis. 
Figure  80.    The  general  appearance  of  the  surface,  except  slight  conges- 


190    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

tion,  usually  is  unchanged.  The  openings  of  the  follicles  scattered  over 
the  labia  minora  and  majora  are  small,  red,  elevated,  and  swollen.  Chil- 
dren are  not  subject  to  folliculitis.  The  inflammation  may  originate 
in  the  follicles  or  may  extend  to  them  from  the  external  surface,  as  in 
glandular  vulvitis.  The  infection  often  remains  entrenched  in  the 
follicles  after  it  has  disappeared  from  the  external  surface,  and  from 
these  lurking-places  may  reinfect  the  surface  again  and  again. 

Adhesive  inflammation  may  close  the  openings  of  the  ducts  ;  then 
the  secretions  will  be  retained  and  form  abscesses  as  large  as  a  pea ; 
otherwise  the  discharge  is  abundant,  purulent,  and  often  offensive. 

Treatment. — The  disease  may  be  seated  so  deeply  that  it  resists  all 
surface  applications,  and  yields  only  to  direct  deep  cauterization 
strong  enough  to  destroy  the  secreting  structures.  For  this  purpose, 
use  the  fine  galvanocautery  needle  or  the  point  of  a  probe  made  red- 
hot  in  the  flame  of  a  spirit-lamp. 

In  follicular  vulvitis  with  occlusion  open  each  follicle  with  a 
small,  sharp-pointed  knife,  and  then  apply  the  fine-pointed  conical 
solid  stick  of  nitrate  of  silver.  This  may  be  done  under  cocaine  with- 
out pain.  A  dressing  of  sterile  gauze  saturated  with  formalin  1  :  1000, 
placed  as  a  pad  over  the  vulva,  is  a  most  serviceable  application.  The 
x-rays  are  used  with  surprisingly  good  results. 

Furuncular  Vulvitis. 

Furnuculosis  usually  starts  in  the  hair-follicles  and  extends  to  the 
surrounding  cellular  tissue.  The  resultant  boil  may  be  developed  at 
numerous  points  in  the  labia  majora,  where  the  disease  usually  is  con- 
fined. Some  women  have  an  unexplained  tendency  to  this  form  of 
vulvitis.  Furunculosis  is  common  in  diabetes.  The  author  has  ob- 
served that  glycerin  tamponade  is  apparently  an  exciting  cause  of 
boils.  The  incipient  boil  may  often  be  aborted  by  pulling  out  the 
hair  from  the  inflamed  hair-bulb,  thereby  giving  drainage. 

The  Treatment  of  furunculosis  is  the  same  in  the  vulva  as  elsewhere 
— i.  g.,  open  and  drain  the  abscess.  Numerous  boils  sometimes  follow 
one  another,  or  occur  in  successive  clusters  in  one  locality.  Such  re- 
curring infection  is  due  usually  to  the  presence  of  the  microbes  of 
suppuration,  which  remain  on  the  surface  ready  to  produce  reinfec- 
tion at  any  favorable  point.  Daily  cleansing  of  the  surface  and 
thorough  disinfection  with  the  ointment  of  biniodide  of  mercury 
(1  :  60)  for  two  weeks  after  the  last  boil  has  disappeared  are  effective 
means  of  prophylaxis.  The  .'r-rays  are  most  efficacious.  General 
tonics  are  decidedly  indicated.  Fresh  brewers'  yeast  taken  in  Mane- 
glassful  doses  four  or  five  times  a  day,  is  a  most  useful  remedy. 

Emphysematous  Vaginitis. 

This  rare  disease  occurs  mostly  in  pregnancy.  It  is  characterized 
by  numerous  small,  soft  cysts  of  variable  size  situated  just  under  the 
surface  and  commonly  on  the  posterior  wall  of  the  vagina.  These 
cysts  contain  serous    fluid   and   gas.     The  affection  usually  is  asso- 


VULVITIS,    VULVOVAGINITIS,    VAGINITIS.  191 

ciated  with  other  forms  of  vaginitis.  The  diagnosis  may  be  verified 
by  pricking  the  cysts  ;  then  the  gas  escapes  with  a  blowing  sound. 
In  pregnant  women  the  cysts  disappear  without  treatment  at  the  end 
of  pregnancy. 

Treatment. — In  puerperal  cases  the  treatment  is  expectant.  In 
non-puerperal  cases,  if  the  cysts  do  not  disappear  under  antiseptic 
douches,  they  should  be  opened  and  the  vagina  packed  with  anti- 
septic gauze. 

Paravaginitis. 

Paravaginitis,  sometimes  called  dissecting  vaginitis,  is  a  rare  dis- 
ease which  involves  the  submucous  connective  tissues.  Burrowing 
abscesses  are  formed  with  perivaginal  fluctuations.  The  musculature 
of  the  vagina  and  vulva,  in  whole  or  in  part,  may  separate  and  slough 
off  in  a  gangrenous  mass.  The  cicatricial  contraction  which  follows 
will  then  cause  stenosis  or  atresia.  It  is  often  impossible  in  such 
cases  to  restore  the  calibre  of  the  vagina  or  vulva  by  operative  meas- 
ures. Secretions  of  blood  or  menstrual  fluid  may  accumulate  above 
the  atresia  in  the  vagina,  uterus,  or  Fallopian  tubes.  This  disease  is 
due  usually  to  a  grave  infection  by  the  streptococcus  or  by  the  germ 
of  diphtheria. 

Treatment. — The  pus  should  be  evacuated  freely  as  soon  as  it  is 
discovered.  If  sinuses  form,  they  should  be  incised  and  drained. 
Plastic  operations  and  dilatation  may  be  required  to  overcome  cicatri- 
cial contraction  and  possible  atresia.  Atresia  from  this  cause  is  to  be 
distinguished  from  the  congenital  atresia  described  in  the  chapter  on 
Malformations. 


CHAPTEK    XII. 

ECZEMA  VULV^,  HERPES  VULVJ3,  KRAUBOSIS  VULV^ 
PRURITUS  VULV^,  HYPERESTHESIA  VULVE,  VAG- 
INISMUS. 

Among  the  disorders  allied  to  vulvovaginal  inflammation  are 
eczema  vulvae,  herpes  vulvae,  kraurosis  vulvae,  pruritus  vulvae,  and 
vaginismus. 

ECZEMA  VULV^. 

Eczema  vulvae  is  an  infrequent  disease,  may  be  acute  or  chronic, 
and  occurs  mostly  during  pregnancy.  Rheumatism,  and  the  uric  acid 
diathesis  are  said  to  be  predisposing  causes.  The  eruption  consists 
of  nodules,  vesicles,  pustules,  and  scabs,  with  more  or  less  redness, 
swelling,  and  moisture  of  the  skin.  The  vesicles  contain  serous  fluid. 
Pus  is  found  under  the  scabs  in  the  more  severe  cases.  The  skin  and 
sometimes  the  subcutaneous  tissues  are  infiltrated.  Acute  eczema 
may  remain  local  and  terminate  within  two  weeks.  Chronic  eczema, 
often  intractable,  may  extend  to  tlie  mons  veneris,  thighs,  and  nates, 
with  swelling  and  suppuration.  The  labia  majora  most  commonly 
are  involved. 

Treatment  of  Eczema  Vulvae. 

The  general  treatment  consists  of  mercurials  and  salines,  non-ii'ri- 
tating  diet,  avoidance  of  wine  and  liquor,  and  hygienic  living.  The 
local  treatment  varies  with  the  condition.  Whenever  the  subcuta- 
neous structures  are  exposed,  the  solid  nitrate  of  silver  point  should 
be  applied,  care  being  taken  to  touch  only  the  exposed  surfaces. 
Oftentimes  numerous  very  minute  abrasions  may  be  seen  with  the 
unaided  eye  or  through  a  magnifying-glass.  These  should  be  touched 
delicately  with  the  finest  point  of  nitrate  of  silver.  The  application 
should  be  repeated  every  five  days  until  the  abrasion  disappears. 
The  following  ointment  is  useful : 

Ointment  of  rose-water 1  ounce. 

Lanolin 2  drachms. 

Oxide  of  zinc 1  drachm. 

Boric  acid - 1       " 

Ammoniated  ichthyol iO  grains 

Thymol 5       " 

The  parts  should  be  kept  clean  and  dry.  Dusting  with  bismuth 
may  give  relief. 

HERPES  VULVAE. 

An  lierpetic  eruption,  not  unlike  herpes  labialis,  is  observed  occa- 
sionally upon  the  vulvar  labia.     There   is   little   redness  or  swelling. 
192 


KRAUROSIS  VULV^.  193 

The  disease   usually  is  self-limited ;  like  herpes  in  other  places,  it 
runs  its  course  in  a  few  days  and  disappears. 

KRAUROSIS   VULV^. 

Kraurosis  vulvae  is  an  atrophic  shrinking  of  the  vulva,  and  is  a 
rare  disease.^  The  aiFection  is  characterized  by  atrophy  of  the  cutane- 
ous covering  of  the  vulva,  especially  of  the  inner  surface  of  the  nym- 
plise.  The  skin  appears  dry  and  shrunken.  The  surface  has  the  tense, 
glistening  appearance  of  scar-tissue.  The  affection  causes  distressing 
paroxysms  of  itching  and  burning  pain  in  the  diseased  part.  Sometimes 
the  vulvar  orifice  is  contracted  extremely.  The  clinical  features  are  so 
characteristic  that  once  recognized  they  will  never  be  mistaken  for 
those  of  any  other  disease.  The  hair  around  the  vulva  is  thin  and 
dry,  and  late  in  the  disease  almost  entirely  absent.  The  vulva  ap- 
pears small  and  infantile,  the  labia  minora  are  shrunken  and,  finallv, 
almost  absent ;  the  skin  is  pale,  without  pigment,  but  studded  with 
numerous  irregularly  shaped  reddish -brown  blood-spots,  M'hich  on 
inspection  appear  slightly  depressed  below  the  surface.  These  spots 
are  confined  entirely  to  the  vestibule,  but  disappear  in  the  later  stages 
of  the  disease.  The  skin  is  dry,  sometimes  cracked,  abraded,  and 
occasionally  gives  forth  a  slight,  brown,  purulent  discharge.  The  nat- 
ural elasticity  of  the  vulva  is  lost  entirely.  The  orifice  is  so  contracted 
as  usually  to  prohibit  the  introduction  of  the  speculum.  The  sen- 
sitiveness of  the  parts  is  very  great,  especially  while  the  brown  spots 
are  present.  This,  together  with  the  tenseness  of  the  vulvar  orifice, 
causes  extreme  dyspareunia ;  in  fact,  usually  prohibits  coition.^ 

Pathology  of  Kraurosis  Vulvae. 

The  pathology  of  this  disease  is  not  fully  known.  In  addition  to 
the  foregoing  pathological  changes  may  be  mentioned  a  thickening  of 
the  layer  of  epidermis,  decrease  in  the  number  of  sebaceous  glands, 
and  sclerosis  of  the  subcutaneous  connective  tissue.  The  tightly  con- 
tracted skin  is  so  stretched  over  the  parts  that  even  the  pressure  of 
the  examining  finger  may  make  deep  rents. 

Longyear  has  observed  a  deep  eirrhotic-like  band  of  fibrous  tissue 
entirely  separate  from  the  cutaneous  covering.  He  regards  this  band 
as  the  essential  lesion,  and  gives  to  the  superficial  changes  a  secondary 
importance.  This  fibrous  band  replaces  the  loose  cellular  tissue 
through  which  the  nutrient  vessels  pass  to  the  skin,  and  by  its  gradual 
and  continual  contraction  causes  not  only  the  vulvar  shrinkage,  but 
also  the  strangulation  of  the  blood-vessels  which  pass  to  and  from  the 
overlying  cutaneous  structures.  This  disturbance  in  circulation  explains 
the  spots  of  ecchymosis  in  the  earlier  stages  of  the  disease,  and  the 
atrophic  changes  in  the  later  stage.  The  pain  is  explained  by  mechan- 
ical pressure  on  the  nerves  and  by  the  resultant  neuritis  and  ])erineuritis. 

1  Rohert  F.  Weir :  "  Ichthyosis  of  the  Tongrne  and  Vulva,"  New  York  Medical  Journal,  Jfarch, 
ISV.S.  Breisky :  "  Kraurosis  Vulvae,"  Centralblatt  fiir  Gvnakologie,  1885,  p  358.  Lawson  Tait :  Dis- 
eases of  Women,  Lea  Bros.  &  Co.,  1889,  p.  53.  C.  A.  Reed:  Trans.  American  Association  of  Obste- 
trici^ans  and  Gynecologists.  1894.     Howard  Longyear  :  Ibid.,  1895. 

-  Adapted  from  Longyear.    American  Obstetrical  Journal,  1895. 

13 


194  INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS 

Kraurosis  in  a  small  proportion  of  cases  is  associated  with  epitheli- 
oma of  the  vulva. 

Treatment  of  Kraurosis  Vulvae. 

This  new  formation  of  fibrous  tissue  is  of  special  interest  from  the 
surgical  standpoint.  Clearly  the  removal  of  this  band,  together  with 
the  contracted  superficial  structures,  is  essential  to  the  cure  of  the 
disease.  The  usual  operation  of  removing  the  degenerated  and  con- 
tracted mucocutaneous  structures  may  relieve  the  acute  symptoms, 
but  can  have  no  effect  on  the  stenosis.  Spontaneous  recovery  some- 
times is  reported ;  but  this  is  only  a  relief  from  the  supersensitiveness 
of  the  vulva,  never  from  the  constriction.  The  fibrous  band,  unless 
removed  by  operation,  is  permanent.  Longyear's  operation  is  the 
removal  of  all  the  superficial  diseased  structures,  together  with  the 
fibrous  band  beneath,  and  union  of  the  external  and  internal  mar- 
gins of  the  wound.  An  incision  with  scissors  is  made  first  along  the 
lateral  and  posterior  margins  of  the  vulvar  orifice,  dividing  the  dis- 
eased structures  from  the  healthy  skin ;  then  the  margin  of  the  dis- 
eased tissue,  including  the  fibrous  band,  is  seized  with  dressing-forceps 
and  dissected  loose  from  the  underlying  tissues  to  the  vaginal  inlet. 
This  tissue  then  is  cut  away.  The  anterior  vulvar  structures  are 
dissected  loose  in  the  same  manner,  care  being  taken  to  cut  carefully 
round  the  urethral  orifice.  After  removing  all  the  diseased  structures 
in  this  way  the  margin  of  the  healthy  vaginal  wall  above  is  pulled 
down  and  dissected  loose  from  the  underlying  parts  around  the  whole 
circumference  of  the  vagina.  This  loosening  of  the  vaginal  wall  per- 
mits the  inner  margin  of  the  wound  to  be  brought  down  to  the  outer 
margin.  The  two  margins  then  are  united  with  deep  silkworm  gut 
and  superficial  catgut  sutures,  or  with  fine  buried  chromic  catgut. 
Complete  relief  has  followed  the  operation.  The  operation  is  similar 
to  that  illustrated  under  the  surgical  treatment  of  Pruritus  Vulvae  in 
this  chapter. 

PRURITUS   VULV-ffi. 

In  neuropathic  cases  of  vulvar  inflammation  the  irritation,  itching, 
and  burning  are  intense,  intolerable,  intractable,  and  thereby  constitute 
a  condition  called  pruritus  vulvae.  The  nervous  element  often  pre- 
dominates, and  for  this  reason  the  disease  has  been  classed  as  a  neurosis. 
It  may  arise  from  a  variety  of  causes,  may  extend  over  the  adjacent 
mucous  surfaces,  and  often  is  aggravated  by  efforts  to  get  relief  by 
scratching ;  in  this  way  the  habit  of  masturbation  sometimes  is  formed. 
The  intense  suffering  causes  loss  of  sleep,  exhaustion,  and  sometimes 
alarming  nervous  depression.  Sexual  excitement  and  orgasms  may 
occur.  Pruritus  may  be  complicated  by  melancholia,  hysteroneuroses, 
and  other  forms  of  insanity.  These  psychoses  may  or  may  not  be 
dependent  on  the  disease.  In  many  cases  a  paroxysmal  wave  recurs 
with  great  violence  upon  exercise  or  upon  getting  into  a  warm  bed. 
The  nervous  element  has  not  been  explained  adequately ;  it  may  be  a 
cause,  or  an  effect,  or  a  coincidence.  Oftentimes  the  inflammatory 
element  is  insignificant  or  apparently  absent. 


I 


PRURITIS  VULV^.  195 

Pathology  of  Pruritus  Vulvae. 

The  pathology  of  pruritus  is  considered  by  some  authorities  to  be 
of  purely  nervous  origin ;  by  others,  who  follow  the  lead  of  modern 
etiological  theories,  to  be  of  bacterial  origin.  The  truth  may  lie  be- 
tween the  two  extremes.  There  may  undoubtedly  be  an  irritation  of 
the  sensory  nerves  of  the  vulvar  skin  of  purely  neuropathic  origin  ; 
when  this  irritation  occurs,  it  usually  is  aggravated  by  the  presence  of 
more  or  less  vulvitis.  The  pathology  so  far  as  it  is  tangible  is  largely, 
therefore,  the  same  as  already  described  under  Vulvitis. 

Etiology  of  Pruritus  Vulvae. 

It  follows  from  the  above  that  the  causes  of  pruritus  will  include 
those  of  vulvitis.  Numerous  attempts  to  explain  the  causation  of 
pruritus  sometimes  have  made  up  in  scientific  elaboration  what  they 
lacked  in  clinical  value.^ 

The  following  classes  of  causes  are  worthy  of  consideration : 

1.  Circulatory  causes. 

2.  Secretory  causes. 

3.  Parasitic  causes. 

4.  Mechanical  causes. 

5.  Thermic  causes. 

1.  Circulatory  Causes. — In  certain  disorders,  such  as  icterus,  dia- 
betes, chronic  nephritis,  the  blood  contains  bile,  urea,  or  sugar,  all  of 
which  by  action  on  the  nerve-endings  are  said  to  cause  itching  of  the 
parts.  Morphine,  alcohol,  and  iodoform  sometimes  produce  a  similar 
eflPect. 

Erythema,  herpes,  urticaria,  and  other  such  skin  disorders  which 
involve  stasis  hyperemia,  may  occur  in  the  region  of  the  pudendal 
and  hemorrhoidal  veins ;  they  then  are  characterized  by  the  intense 
pruritus  which  they  cause. 

2.  Secretory  Causes. — Abnormal  secretions  of  the  vulva,  vagina, 
or  uterus,  especially  if  combined  with  the  above-mentioned  causes, 
may  produce  great  irritation  in  the  terminal  sensory  nerves  of  the 
vulva.  Secretions  from  the  diseased  bowel  or  anus  by  chemical  action 
may  produce  pruritus  ani  and,  by  extension,  give  rise  to  pruritus 
vulvae. 

3.  Parasitic  Causes. — Animal  parasites,  such  as  pediculi  and 
ascarides,  and  vegetable  parasites,  such  as  leptothrix,  oi'dium,  and 
leptomitus,  and  the  ordinary  bacteria  of  inflammation,  have  been  pre- 
sented under  Vulvovaginitis. 

4.  Mechanical  Causes  include  masturbation,  immoderate  hand-' 
ling,  and  scratching. 

5.  Thermic  Causes. — Heat  and  cold  are  known  to  set  up  a  pecu- 
liar pruritus,  called  in  winter  pruritus  hiemalis  and  in  summer  pruritus 
aestivalis. 

Above  all  these  causes  another  and  more  essential  element  must  be 
taken  into  the  account ;  it  is  what  Goodell  once  called  the  invisible, 

,     i.A  ™ost  elaborate  and  scientific  discussion  of  the  etiology  of  pruritus  has  been  contributed 
by  Sanger.    Centralblatt  fUr  Gyniikologie,  1894,  No.  7. 


196    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

intangible,  and  imponderable  influence  on  the  nervous  system  ;  it  is 
the  difficulty,  not  to  say  the  impossibility,  of  reckoning  with  this  ele- 
ment tliat  often  makes  the  disorder  persistent  or  intractable.  The 
most  that  can  be  affirmed  with  our  present  limited  knowledge  is  that 
there  is  an  irritation  of  the  sensory  nerve-organ  of  the  skin,  and  that 
many  causes  may  contribute  to  its  excessive  development.  Whatever 
the  tangible  lesion  may  be,  nervous  irritability  and  hypersesthesia  are 
always  essential  elements. 

Intolerable  itching  of  the  anus  is  a  frequently  recognized  accom- 
paniment of  habitual  constipation,  and  often  is  associated  with  pruri- 
tus vulvae  and  hemorrhoids.  This  may  be  explained  by  the  fact  that 
the  vulva  is  supplied  by  the  same  nerves  that  supply  the  anus.  The 
intestinal  toxins  which  have  been  recognized  as  a  cause  of  pruritus 
ani  therefore  may  cause  pruritus  vulvse  also. 

Symptoms  and  Course  of  Pruritus  Vulvae. 

The  irritation  is  apt  to  occur  in  paroxysmal  waves.  The  paroxysms 
may  recur  after  vigorous  exercise,  especially  in  warm  weather,  before 
or  after  menstruation,  or  upon  exposure  to  artificial  heat.  In  some 
cases  they  appear  upon  getting  into  a  warm  bed.  The  desire  to  rub 
or  scratch  for  the  relief  of  the  irritation  is  almost  irresistible.  This 
instinctive  effort  at  counterirritation  greatly  aggravates  the  pruritus. 
As  Thomas  aptly  remarks,  "  the  disease  and  the  remedy  which  instinct 
suggests  react  upon  one  another,  the  first  requiring  the  second,  and 
the  second  aggravating  the  first,  until  a  most  rebellious  and  deplorable 
condition  is  developed  ;  the  patient,  bereft  of  sleep  by  night  and  tor- 
mented constantly  by  day,  finally  gives  way  to  despondency  and  de- 
pression." The  loss  of  sleep,  the  use  and  abuse  of  anodynes,  and  the 
neurosis  incident  to  the  disease  may  contribute  to  the  development  of 
melancholia  or  some  other  form  of  insanity. 

The  pruritus  may  extend  to  the  vagina,  anus,  thighs,  and  abdomen. 
In  some  cases  the  irritation  begins  in  the  anus. 

Diagnosis  and  Prognosis  of  Pruritus  Vulvae. 

Pruritus  is  not  a  disease,  but  a  symptom  ;  diagnosis  must  depend 
therefore  upon  the  identification  of  the  causative  lesion.  In  so  far  as 
the  disease  depends  upon  tangible  and  visible  conditions  the  diagnosis 
and  prognosis  will  follow  along  the  lines  laid  down  in  Chapter  XL, 
on  Vulvitis.  In  a  majority  of  cases  a  clear  appreciation  of  the  special 
etiology  of  the  disorder  as  given  above  will  open  the  way  to  accurate 
diagnosis. 

Without  great  care  the  examination  may  fail  to  disclose  the  point 
and  source  of  irritation.  An  irritating  discharge,  for  example,  so 
slight  as  to  be  unknown  or  ignored  by  the  patient,  may  be  sufficient 
to  produce  the  most  distressing  pruritus,  and  may  therefore  have  the 
utmost  significance. 

In  the  vast  majority  of  cases  one  or  more  of  the  following  condi- 
tions will  be  found  present,  and  will  explain  partially  or  wholly  the 
irritation  : 


PBUBITUS   VULVM  197 

Vulvitis ;  Ichorous  discharge  from  cancer ; 

Vaginitis  ;  Incontinence  of  urine  ; 

Endometritis ;  Pathological  urine  ; 

Urethritis  ;  Intestinal  disease  ; 

Urethral  caruncle  ;  Vulvar  eruptions ; 

Parasites ;  Onanism. 

Most  commonly  associated  with  pruritus  are  vulvitis,  vaginitis,  and 
endometritis.  The  fact  that  these  diseases  do  not  commonly  produce 
the  disorder  is  explained  by  the  absence  of  the  essential'  neurosis. 
Senile  vulvovaginitis  is  most  prone  to  cause  excessive  irritation,  and 
the  pruritus  when  due  to  this  cause  is  exceedingly  obstinate. 

The  pruritus  of  pregnancy  and  the  menopause  is  limited  commonly 
to  those  states.     In  general  the  prognosis  is  indeterminate. 

Treatment  of  Pruritus  Vulvae. 

The  treatment  of  vulvovaginitis- already  laid  down  is  necessarily 
a  part  of  the  treatment  of  pruritus  vulvae. 

A  multiplicity  of  remedies  recommended  in  the  therapy  of  any 
disorder  may  be  taken  as  evidence  that  our  resources  are  limited  or 
that  the  disorder  may  result  from  one  or  more  of  a  wide  variety 
of  pathological  conditions.  Both  of  these  propositions  are  true  of 
pruritus  vulvae. 

It  is  clear  that  the  treatment  must  be  directed  to  the  cause  of  the 
irritation  ;  to  this  end  the  reader  is  referred  to  tlie  therapv  of  vulvo- 
vaginitis and  of  the  numerous  diseases  and  disorders  already  mentioned 
under  Etiology  and  Diagnosis.  See  especially  the  treatment  of  senile 
and  mycotic  vulvovaginitis ;  in  the  treatment  of  the  latter  is  the 
formula  of  an  ointment  containing  camphor,  chloral  hydrate,  menthol, 
carbolic  acid,  and  lanolin,  which  may  be  used  to  advantage  in  various 
forms  of  pruritus. 

In  many  cases  the  irritation  is  apparently  the  outcome  of  pent-up 
sexual  energy.  A  neurotic  woman  who  suffers  intensely  from  pruritus 
has  experienced  entire  relief  upon  the  return  of  her  husband  from  a 
prolonged  absence. 

While  the  radical  treatment  is  in  progress  palliative  measures 
always  are  demanded  for  the  immediate  relief  of  urgent  symp- 
toms. Fortunately,  most  of  the  palliative  measures,  since  they  allay 
irritation,  are  in  a  degree  curative.  Sitz-baths  and  vaginal  douches 
of  water  or  antiseptic  solutions  are  useful  to  remove  irritating  dis- 
charges. 

The  following  local  applications  may  give  relief: 

The  surfaces  after  each  bath  m-ay  be  dried  and  freely  dusted  with 
calomel,  bismuth,  starch,  or  lycopodinm  powder.  The  calomel  is  gen- 
erally preferable. 

A  vaginal  tampon  of  gauze  often  will  protect  the  vulva  from  the 
discharge,  and  thereby  give  temporary  relief. 

Great  relief  sometimes  is  experienced  from  a  gauze  compress  over 
the  vulva,  saturated  with  dilute  solution  of  subacetate  of  lead  and 
laudanum,  equal  parts.     The  compress  should  be  changed  frequently. 


198    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

A  compress  saturated  with  a  solution  of  corrosive  sublimate, 
1  :  1000,  or  some  form  of  mercurial  inunction  will  act  as  if  by  magic 
when  the  cause  is  parasitic. 

Figure  81. 


A,  radical  operation  for  krauroses  or  pruritus  vulvae.  The  black  and  white  dotted  lines 
indicate  the  direction  of  the  incisions  in  the  radical  operation  for  kraurosis  or  pruritis  vulvse. 
The  inner  incision  in  extreme  cases,  involving  the  lower  part  of  the  vagina,  especially 
kraurosis,  would  usually  have  to  include  the  introitus  vaginae.  B,  diseased  structures  re- 
moved. C,  three  sutures  in  place  and  tied,  one  suture  being  introduced.  D,  operation  being 
completed  by  the  introduction  of  the  last  suture. 

Cloths  wrung  out  in  very  hot  water  and  applied  to  the  vulva  may 
relieve  or  prevent  the  paroxysm  which  comes  on  after  going  to  bed. 
A   strong  infusion  of  tobacco,  according   to   Thomas,    both  as  a 


HYPERESTHESIA   OF  THE  VULVA.  199 

vaginal  douche  and  on  the  vulvar  compress,  is  most  efficacious.  In 
a  case  in  which  the  neurotic  element  prevailed,  he  observed  prompt 
and  complete  relief  from  the  smoking  of  tobacco. 

Ointments  are  useful  from  the  soothing  effect  of  their  constituents 
and  because  they  protect  the  parts  from  contact  with  irritating  dis- 
charges. They  are  also  an  excellent  vehicle  for  the  application  of 
parasiticides. 

In  rare  cases  the  pruritus  is  due  to  a  growth  of  short,  stiff,  inverted 
hair  on  the  labia  majora  or  pubes.  This  condition  is  called  trichiasis. 
Prompt  and  permanent  relief  follows  removal  of  the  hairs  and 
destruction  of  their  bulbs  by  electrolysis. 

The  treatment  of  the  disorder,  if  due  to  the  diabetic,  uric  acid, 
or  other  diathesis,  must  include  the  appropriate  hygienic  measures, 
especially  diet. 

Painting  the  vulva  with  pure  ichthyol  has  been  known  to  effect  a 
radical  cure.  In  a  case  observed  by  the  writer  an  accidental  applica- 
tion of  pure  carbolic  acid  was  followed  by  permanent  cure. 

Highly  seasoned  and  highly  nitrogenous  food  and  stimulating  bev- 
erages aggravate  the  irritation,  and  should  be  avoided.  For  the  same 
reason  scratching  and  rubbing  of  the  part  are  injurious. 

Finally,  there  is  danger  of  forming  the  habit  of  using  cocaine,  mor- 
phine, or  other  narcotics  j  for  this  reason  their  use  should  be  guarded 
with  judgment. 

When  apparent  causes  have  received  due  attention,  and  the  dis- 
ease has  resisted  all  treatment,  operative  interference  may  become 
necessary. 

Sanger's  conclusions  on  this  point  are  based  upon  experience,  and 
deserve  attention.     He  says  : 

1.  The  partial  or  total  extirpation  of  the  vulva  is  a  legitimate  ope- 
ration which  should  be  performed  in  chronic,  otherwise  incurable 
pruritus  vulvae.     He  calls  the  disease  vuhiius  pruriginoso. 

2.  The  removal  of  the  glans  clitoridis,  especially  in  elderly  women, 
in  whom  the  nerve  terminations  have  usually  lost  their  specific  sensi- 
bility by  reason  of  the  disease,  is  permissible. 

3.  In  younger  persons,  if  the  irritation  is  circumscribed,  one 
may  try  to  give  relief  by  a  partial  operation  without  removal  of  the 
clitoris.  In  elderly  women,  and  sometimes  even  in  younger  women, 
when  the  disorder  is  extensive,  the  whole  vulva  should  be  extirpated 
and  the  parts  repaired  by  a  corresponding  plastic  operation.  See 
Surgical  Treatment  of  Kraurosis  Vulvae. 

HYPERESTHESIA  OF  THE  VULVA. 

Thomas  has  described,  under  this  name,  a  rare  disorder  of  the 
vulva  which  occurs  in  hysterical  and  despondent  women  at  or  near  the 
menopause.  It  consists  of  an  excessive  sensibility  of  the  nerves  sup- 
plying the  mucous  membrane  of  some  part  or  all  of  the  vulva.  The 
slightest  friction  excites  intolerable  pain  and  nervousness  ;  even  a  cur- 
rent of  cold  air  produces  discomfort,  and  the  least  pressure  is  intoler- 
able.   Sexual  intercourse  is  often  impossible.    The  disease  sometimes  is 


200    INFECTIONS,   INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

associated  with  vulvitis  or  a  painful  urethral  caruncle  ;  in  other  cases 
no  tangible  or  visible  cause  can  be  found.  It  differs  from  pruritus 
by  the  absence  of  itching,  and  from  vaginismus  in  not  causing  spas- 
modic contraction  of  the   vagina. 

Treatment  of  Hypersesthesia  of  the  Vulva. 

The  treatment  is  unsatisfactory.  Both  the  complete  destruction 
of  the  mucous  membrane  of  the  sensitive  area  M'ith  caustics,  and 
excision,  have  failed  to  give  relief  Sexual  intercourse  should  be 
prohibited  and  the  patient  placed  in  hygienic  surroundings  with  cheer- 
ful company.  The  general  treatment  is  by  tonics,  sea-bathing  or 
warm-water  bathing,  and  massage.  Local  lesions,  if  present,  are 
treated  according  to  their  special  indications. 

VAGINISMUS. 

Like  pruritus  vulvae,  vaginismus  is  not  a  disease,  but  a  ner- 
vous symptom  due  in  some  cases  to  appreciable,  in  others  to  un- 
known causes.  It  is  characterized  by  spasmodic  contractions  of 
the  muscles  surrounding  the  vulva  and  lower  portion  of  the  vagina. 
The  condition  is  analogous  to  laryngismus.  The  spasms  occur  upon 
attempted  coitus  or  upon  the  atteitipt  to  make  a  digital  or  speculum 
examination.  The  writer  has  observed  one  strongly  neurotic  case  in 
which  the  woman  declared  that  the  spasm  occurred  violently  whenever 
coitus  was  attempted,  but  not  the  slightest  objection  was  made  to 
digital   or  speculum   examination. 

Etiology  and  Clinical  Course  of  Vaginismus. 

The  condition  is  confined  mostly  to  young  neurotic,  hysterical 
women.  The  palpable  or  visible  lesion  is  usually  in  the  form  of  an 
irritable  hymen  or  an  irritable  caruncle  of  the  meatus  urinarius.  If 
the  hymen  has  been  ruptured,  the  irritation  will  be  in  the  remains 
of  it — the  carunculse  myrtiformes.  These  caruncles  and  the  urethral 
caruncle  in  some  cases  contain  a  superabundance  of  excessively  sen- 
sitive nerve-filaments.  They,  in  fact,  may  resemble  neuromata.  In 
other  cases  the  sensitive  caruncles  are  absent,  and  the  vaginismus  is 
characterized  only  by  an  excessively  sensitive  vaginal  outlet,  w'hich 
may  or  may -not  be  the  seat  of  inflammation  or  erosion.  Repeated 
attempts  at  coitus  against  an  unyielding  intact  hymen  may  give  rise 
to  vulvitis  and  extreme  tenderness — a  condition  which  should  not  be 
confounded  with  vaginismus. 

There  may  be  no  appreciable  cause  of  the  disorder  save  a  progres- 
sively increasing  nervous  apprehension  on  the  part  of  the  wife  ;  each 
attempt  gives  rise  to  greater  nervous  excitement  until  the  pain  and  fear 
of  coitus  and  the  extreme  spasmodic  contraction  of  the  levator  ani 
and  neighboring  muscles  wdiich  form  the  sphincter  vaginae  preclude 
the  possibility  of  a  successful  effort.  Thomas  has  given  to  this  dis- 
tressing symptom  the  name  "  dyspareunia."  "  Penis  captivus  "  has 
been  known  to  result  from  an  otherwise  normal  coitus. 


VAGINISMUS.  201 

Treatment  of  Vaginismus. 

Any  discoverable  local  cause  should  be  removed.  A  vulvar  tam- 
pon of*  gauze  saturated  with  a  4  per  cent,  solution  of  cocaine,  kept  in 
place  ten  minutes  before  the  attempt,  may  lead  to  successful  coitus, 
and  therefore  to  utero-gestation  and  parturition,  which  in  most  cases, 
though  not  in  all,  effects  a  cure. 

Vulvar  inflammation  and  erosion  require  the  treatment  described 
under  Vulvovaginitis.  Excision  of  the  irritable  caruncles  and 
gradual  or  forcible  dilatation  of  the  vagina  have  in  many  cases  given 
relief  The  mere  division  of  a  rigid  or  imperforate  hymen  may  be 
sufficient  to  remove  the  obstacle.  Gradual  dilatation  is  made  by  the 
introduction  of  graduated  rectal  bougies,  to  be  worn  an  hour  or  more 
daily.  Forcible  dilatation  requires  ether,  and  should  be  followed  by 
the  continued  wearing  of  a  Sims  vaginal  plug.  Meantime  the  patient 
remains  in  bed  until  the  divulsed  vaginal  walls  have  healed.  The 
plug  should  be  removed  only  during  urination,  defecation,  and  the 
giving  of  the  vaginal  douche  ;  after  healing,  it  may  be  introduced 
daily  by  the  patient  in  order  to  retain  the  effects  of  the  divulsion.  In 
obstinate  cases  divulsion  will  be  inadequate.  It  is  sometimes  neces- 
sary to  incise  deeply  at  several  points  or  to  make  two  quite  deep 
lateral  incisions  on  either  side  near  the  posterior  vulvar  commissure. 
These  incisions  should  divide  completely  the  underlying  muscles  and 
their  fascia ;  they  may  be  closed  by  lines  of  union  running  at  right 
angles  to  the  directions  in  which  the  incisions  were  made,  or  until 
healing  is  established  they  may  be  kept  open,  as  already  described, 
by  means  of  the  vaginal  plug.     See  index  for  Sims:'-  vaginal  plug. 


CHAPTER    XIII. 

METRITIS— INFLAMMATION  OF  THE  UTERUS. 

General   Considerations. 

This  chapter  should  be  read  in  connection  with  Chapter  X.,  on 
the  General  Principles  of  Infection  and  Inflammation  of  the  Pelvic 
Organs ;  and  Chapters  XIV.  to  XVIIL,  which  treat  of  metritis  as  it 
aifects  the  various  parts  of  the  uterus. 

Inflammation,  broadly  defined  as  the  reaction  which  living  tissue 
exhibits  to  morbid  irritation,  may  include  a  wide  variety  of  lesionSi 
These  lesions,  as  related  to  the  uterus,  have  variously  and  sometimes 
vaguely  been  designated  as  chronic  metritis,  subacute  metritis,  subin- 
flammatory  states,  irritative  states,  and   congestive  states. 

Anatomy  and  Physiology. — Before  entering  upon  the  study  of 
metritis,  which  is  the  study  of  the  anatomy  and  physiology  of  the 
uterus  as  modified  by  inflammation,  the  following  suggestion  of  such 
parts  of  the  anatomy  and  physiology  as  will  aid  in  a  descrij)tion  of 
these  inflammatory  processes  will  be  useful. 

The  interior  of  the  uterus  is  divided  into  two  cavities,  the  cavity 
of  the  cor})us  and  the  cavity  of  the  cervix.  The  former  is  protected 
somewhat  from  infection  from  above  by  the  two  muscular  constrictions 
which  divide  it  from  the  Fallopian  tubes  ;  from  below  by  a  similar 
arrangement  at  the  internal  os.  The  cavity  of  the  cervix  is  protected 
in  like  manner  from  infection  from  above  by  the  internal  os ;  from 
below  by  the  external  os. 

The  Uterine  Wall  is  made  up  of  three  layers  :  the  mucous  layer, 
called  the  endometrium ;  the  muscular  layer,  called  the  myometrium, 
consisting  of  three  coats  ;  and  the  serous  or  peritoneal  layer,  some- 
times called  the  perimetrium. 

The  Endometrium  is  composed  of  lymphatics,  blood-vessels,  nerves, 
glands,  and  connective-tissue  cells,  and  is  covered  by  a  single  layer 
of  ciliated  columnar  epithelium.  This  epithelium  also  lines  the 
uterine  glands  and  is  continued  through  the  Fallopian  tubes.  The 
same  variety  of  epithelium,  modified,  also  lines  the  cavity  of  the 
cervix  uteri.  Pavement  epithelium,  beginning  at  the  external  os, 
covers  the  external  vaginal  portion  of  the  cervix. 

The  Glands  of  the  Corpus  Uteri  are  tubular,  narrow,  branching 
depressions.  They  dip  down  into  and  through  the  endometrium  and 
penetrate  to  the  muscularis.  These  tubular  glands,  penetrating 
everywhere  throughout  the  endometrium,  make  up  a  very  large  part 
of  its  volume.  They  all  open  into  the  uterine  cavity,  sometimes  two 
by  a  single  orifice. 

The  corporeal  endometrium  is  bound  firmly  to  the  inner  coat  of 

202 


METRITIS— INFLAMMATION  OF  THE   UTERUS. 


203 


the  muscularis  by  connective  tissue  wliich  is  continuous  with  that  of 
the  myometrium. 

Lymph-  and  Blood-vessels  and  Nerves. — The  lymph-spaces  and  lymph- 
vessels  of  the  uterus  are  abundant  in  the  endometrium,  in  the  muscular 
strata,  and  in  the  serosa.  Converging,  they  pass  by  large  channels 
outward  through  the  broad  ligaments.  Figure  83,  and  the  Frontis- 
piece, Plate  I.  The  uterus  is  supplied  richly  with  nerves,  both  spinal 
and  sympathetic.  The  arteries  and  veins  are  illustrated  in  the 
Frontispiece  and  in  the  chapter  on  Myomata,  under  myomectomy. 

Figure  82. 


Long  section  of  the  uterus  and  adjacent  parts— rectum,  vagina,  and  bladder.  The  layers 
of  the  uterine  wall  are  indicated;  they  are  the  raucous  layer  or  endometrium,  the  three  muscu- 
lar layers  comprising  the  myometrium,  and  the  serous  or  peritoneal  layer,  known  as  the  peri- 
metrium. 

The  Minute  Anatomy  of  the  Cervix  differs  from  that  of  the  corpus 
uteri  in  the  following  particulars.  Its  mucous  surface  has  a  peculiar 
arbor  vitfe  appearance,  as  shown  in  Figures  84  and  85.  The  upper 
two-thirds  of  the  intracervical  mucosa,  like  the  corporeal,  is  lined 
Avith  a  single  layer  of  ciliated  columnar  epithelial  cells,  which,  simi- 
lar to  those  of  the  corpus,  and  modified  to  the  shape  of  a  cup,  pass 
without  cilia  into  the  cervical  glands ;    the  epithelium  in  the  lower 


204    INFECTIONS,   INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Figure  83. 


Lymphatics  of  the  uterus. 

third  gradually  changes  to  squamous  epithelium,  and  at  the  os  exter- 
num is  continuous  with  the  squamous  epithelium  of  the  vagina.  The 
connective-tissue  cells  are  closer  together  in  the  cervical  than  in  the 


FiorRE  84. 


Figure  85. 


^'^    ^ 


'/ejj?»!iriAv^ 


Figure  84. — Arbor  vitse  arrangement  of  cervical  mucosa.    Natural  size. 
Figure  85. — Arbor  vitae  appearance  of  cervical  mucosa.    Magnified. 

corporeal  mucosa,  but  the  cervical  mucosa,  more  dense  than  the  cor- 
poreal, is  bound  less  firmly  to  the  muscularis  by  looser  connective 
tissue. 


METRITIS— INFLAMMATION  OF  THE    UTERUS.  205 

An  important  function  of  the  cervix  is  that  of  a  sphincter  to  sepa- 
rate the  corpus  uteri  from  the  vagina.  The  normal  secretion  of  the  . 
uterine  glands  is  alkaline,  that  of  the  corpus  clear  and  watery,  that 
of  the  cervix  clear  and  viscid.  A  yellow  secretion  is  evidence  of  dis- 
ease. The  minute  anatomy  of  the  uterine  mucosa  will  be  described 
in  Chapter  XVI.  on  Chronic  Endometritis. 

The  essential  function  of  the  corporeal  mucosa  is  the  formation  of 
the  decidua  and  the  nourishing  of  the  embryo.  The  connective-tissue 
cells  produce  the  cells  of  the  decidua  of  pregnancy ;  this,  with  the 
progress  of  uterogestation,  matures,  becomes  over-ripe,  degenerates, 
and,  being  of  no  further  use,  at  term  is  cast  off.  The  cervical  mucosa 
has  no  part  in  menstruation. 

The  most  significant  factor  in  metritis  is  the  endometrium.  It 
exhibits  in  the  developmental  and  atrophic  changes  of  puberty  and 
the  menopause,  in  the  vascular  changes  of  the  menstrual  ebb  and  flow, 
widely  and  constantly  varying  states.  Inflammation  of  the  uterus 
may  occur  during  infancy,  before  the  endometrium  has  matured ; 
during  puberty,  when  it  is  maturing;  during  maturity,  when  it  has 
reached  its  full  physiological  significance ;  during  the  menopause, 
when  it  is  undergoing  degeneration  ;  or  during  senility,  when  in  the 
physiological  sense  it  has  disappeared  forever.  The  occurrence  of 
metritis  under  such  diverse  conditions  partly  explains  the  wide  and 
variable  range  of  its  phenomena  and  the  difficulty  of  description,  and 
partly  accounts  for  the  confusion  of  classification  and  nomenclature 
which  runs  through  the  literature. 

Classification  of  Metritis. 

The  general  subject,  classification  of  infection  and  inflammation, 
has  been  discussed  in  Chapter  X.  The  current  classifications  of 
metritis  are  numerous  and  faulty. 

The  Etiological  Classification  is  based  upon  predisposing  causes, 
such  as  parturition  or  traumatism,  and  upon  the  bacterial  causes.  The 
difficulty  in  identifying  the  causes  and  in  differentiating  between  the 
many  causes  in  a  given  case  detracts  from  the  value  of  the  etiological 
classification  as  a  clinical  guide.  A  hadcriological  classification  may, 
under  conditions  of  more  exact  knowledge,  ultimately  become  a  prac- 
tical diagnostic,  prognostic,  and  therapeutic  guide.  Already  indica- 
tions point  strongly  in  this  direction. 

The  Pathological  Classification,  so-called,  into  catarrhal,  suppu- 
rative, granular,  and  ulcerative  inflammations,  is  rather  a  designation 
of  certain  phases  of  the  inflammatory  process  than  a  classification. 

The  Anatomical  Classification  includes  endometritis  (corporeal 
and  cervical),  myometritis,  parametritis,  and  perimetritis.  If  these 
varieties  usually  occurred  as  distinct  circumscribed  lesions,  instead  of 
complicating  one  another  ;  if  each  could  be  known  by  its  own  peculiar 
symptom-group ;  if  ordinarily  one  could  be  separated  clinically  from 
the  other — then  the  anatomical  classification  would  not  be,  as  it  is, 
impractical  and  misleading.  Endometritis,  for  example,  cannot  long 
continue  without  involvement  of  the   myometrium,  and   vice  versa. 


206    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Greneral  metritis  includes  the  peritoneal  covering  of  the  uterus.  There 
are  no  sharp  clinical  or  pathological  lines  of  demarcation  between  the 
anatomical  divisions  of  uterine  and  peri-uterine  infection. 

To  illustrate  the  hopelessness  of  the  attempt  to  classify  metritis, 
observe  the  following  from  an  otherwise  excellent  modern  treatise. 
This  work  classifies  metritis  into  (1)  acute  inflammatory,  (2)  hemor- 
rhagic, (3)  catarrhal,  (4)  chronic  painful.  In  the  first  division  the 
word  inflammatorv  is  tautological.  Any  of  the  so-called  varieties 
may  be  hemorrhagic,  catarrhal,  or  painful.  It  is  possible,  therefore, 
to  retain  of  this  classification  but  two  words — acute  and  chronic.  The 
following  paragraphs  will  show  still  further  that  any  elaborate  attempt 
at  definite  classification,  even  though  diagrammatically  attractive,  is 
clinically  impossible. 

Nomenclature  of  Metritis. 

The  nomenclature  of  the  foregoing  paragraphs,  although  not  the 
outgrowth  of  adequate  classification,  is  yet  useful  as  a  means  of  nam- 
ing certain  forms  and  phases  of  metritis.  Such  words  as  gonorrhoeal, 
parenchymatous,  and  catarrhal  are  convenient  for  purposes  of  descrip- 
tion. The  name  endometritis,  for  example,  will  be  used  to  describe 
not  a  distinct  lesion  independent  of  the  rest  of  the  uterus,  but  rather 
an  essential  part  of  uterine  infection.  In  this  way  m'c  shall  not  lose 
sight  of  the  clinical  relations  between  the  various  forms  and  phases 
of  metritis. 


CHAPTER   XIV. 


ACUTE  METRITIS. 


When  infection  reaches  the  uterus,  it  usually  attacks  first  the 
mucosa,  and  then  may  extend  to  the  myometrium  and  perimetrium. 
Metritis  is  therefore  a  combination  of  endometritis,  myometritis,  and 
perimetritis.  The  storm-centre  of  the  infection  is  usually  the  en- 
dometrium, and  the  essential  lesion  endometritis.  It  is  impossible  to 
draw  definite  lines  of  division  between  these  three  forms  of  metritis. 
The  terms  endomeinfis,  myometritis,  and  perimetritis  v:ill  be  used  there- 
fore not  to  describe  separate  and  distinct  lesions,  but  rather  to  identify 
the  morbid  changes  that  may  occur  in  definite  parts  of  an  injected 
uterus. 

Etiology  of  Acute  Metritis. 

The  general  subject  of  etiology  has  been  outlined  in  the  chapter 
on  the  General  Principles  of  Pelvic  Inflammations. 

Predisposing  Causes. — Those  influences  that  induce  pelvic  con- 
gestion are  favoring  conditions  for  metritis ;  they  are  : 

1.  Menstrual  congestion. 

2.  Suppression  of  the  menses. 

3.  Displacements. 

4.  Constriction  and  consequent  obstruction  in  the  uterine  canal. 

5.  The  improper  use  of  pessaries. 

6.  Parturition  and  abortion. 

7.  Traumatisms. 

8.  Excessive  coitus. 

Formerly  these  conditions  and  others  like  them  were  supposed 
to  be  the  essential  causes.  Now  it  is  known  that  they  contribute  to  the 
production  of  metritis  as  predisposing  causes  when  supplemented  by 
some  other  influence.  This  influence  is  the  exciting  cause,  is  usually, 
at  least,  bacterial  and  produced  from  without,  seldom  from  within. 

Exciting  Causes. — Among  the  exciting  causes  numerous  bacteria 
and  their  products  predominate.  These  bacteria  have  been  discussed 
partially  in  the  General  Principles  of  Inflammation,  Chapter  X., 
and  in  the  Etiology  of  Vulvovaginitis.  They  usually  invade  the 
cavity  of  the  cervix  uteri  from  below,  intrench  themselves  in  the 
cervical  glands,  and  thence  mav  be  distributed  directly  by  continuity 
of  surface  or  tissue  to  the  endometrium,  the  Fallopian  tubes,  ovaries, 
and  pelvic  peritoneum.  Bacteria  may  also  pass  directly  by  the  lym- 
phatic or  venoub  circulation  from  the  cervix,  vagina,  rectum,  or 
bladder  to  the  ovaries  and  peritoneum.  From  these  organs  they 
may  descend  by  continuity  of  the  mucosa  through  the  tubes  to  the 
endometrium. 

207 


208    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

The  cavities  of  the  cervix  and  corpus  uteri,  especially  the  latter, 
are  normally  free  from  pathogenic  bacteria ;  bacteria  may,  however, 
easily  find  access  to  these  parts,  and  will  then  be  active  or  inactive 
according  to  the  degree  of  resistance  which  the  tissues  exhibit  to  their 
presence.  The  corporeal  and  cervical  mucosa,  penetrated  throughout 
with  a  great  abundance  of  tubular  glands,  are  adapted  especially  to 
incubate  and  distribute  bacteria.  This  accounts  for  the  tendency  of 
metric  and  perimetric  infection  to  become  chronic. 

The  gonococcus  of  Neisser,  since  it  has  great  power  to  penetrate 
the  glandular  elements  and  to  intrench  itself  therein,  is  one  of  the 
most  frequent  and  destructive  causes  of  metritis.  The  staphylocoeci 
of  suppuration  are  found  commonly  also  in  suppurative  endometritis. 
The  streptococcus  p>yogenes,  very  infectious  and  fatal,  produces  one 
of  the  graver  forms  of  puerperal  and  traumatic  pelvic  infection. 
The  great  danger  of  this  germ  is  in  the  fact  that  it  does  not  strongly 
attract  leucocytes,  and  therefore  does  not  excite  defensive  action. 
The  diphtheria  and  tubercle  bacilli.  Bacilli  coli  communis,  and  other 
bacteria  may  also  be  the  exciting  causes  of  metritis.  Infection  is 
introduced  often  from  want  of  cleanliness  during  the  puerperal  state, 
from  imperfect  ase])sis  in  parturition,  in  treatment,  and  in  surgical 
operations.     Direct  infection  through  coition  is  common. 

During  the  three  or  four  days  after  parturition  and  just  before 
menstruation  the  physiological  congestion  of  the  uterus  renders  it 
most  susceptible  to  infection.  The  cervical  portion  at  all  times  is  apt 
to  be  the  habitat  of  pathogenic  germs ;  such  germs  often  are  intro- 
duced by  the  physician's  finger,  or  upon  septic  instruments  of  which 
the  unclean  uterine  sound  is  a  striking  example.  The  infectious 
material  may  be  inactive  unless  the  soil  is  prepared  to  receive  and 
develop  it ;  but  when  the  traumatisms  of  abortion  and  parturition, 
of  accident  and  of  surgery,  have  opened  wide  the  door  for  bacterial 
invasion,  infection  will  be  the  natural  result. 

Pathology  of  Acute  Metritis. 

The  lyraph-channels  and  blood-vessels  bring  into  direct  and  close 
communication  with  one  another  the  endometrium,  myometrium,  para- 
metric cellular  tissue.  Fallopian  tubes,  ovaries,  and  peritoneum.  The 
uterine  mucosa  thus  becomes  both  the  starting-point  and  the  distrib- 
uting-point of  the  infection.  The  infected  endometrium  may  abun- 
dantly pour  its  toxic  products  through  the  lymph-  and  blood-streams, 
with  resultant  lymphangitis,  phlebitis,  cellulitis,  salpingitis,  peritonitis, 
and  ovaritis.  The  infection  may  s])read  from  the  endometrium  not 
only  by  the  vessels,  but  also  by  continuity  of  mucosa  to  the  Fallopian 
tubes,  peritoneum,  and  ovaries,  or  in  like  manner  may  descend  from 
these  organs  to  the  endometrium. 

The  close  physiological  and  anatomical  relations  of  the  lymph- 
stream  to  the  endometrium  and  uterine  peritoneum  partially  explain  the 
swift  and  terrible  march  of  the  traumatic  and  puerperal  infections  to  a 
destructive  or  even  fatal  result.  The  toxins,  usually  streptococci  or  other 
pus  cocci  and  their  products,  are  taken  up  and  widely  distributed  by  the 


ACUTE  METRITIS.  209 

lymphatics  or  veins.  They  may  be  carried  through  the  vessels  without  in- 
fecting them,  or  may  infect  them  and  produce  lymphangitis,  lymphadeni- 
tis, or  phlebitis.  The  inflammation  may  be  so  intense  as  to  destrov 
the  vessels,  or  resolution  may  bring  about  complete  recovery.  Inflam- 
mation in  the  lymphatics  or  veins  may  result  in  lymph  thrombosis  or 
venous  thrombosis.  This  is  nature's  way  of  limiting  the  spread  of 
the  infection.  When  recovery  takes  place,  the  lymph-  or  blood-stream 
is  re-established  around  the  thrombosed  parts  of  these  vessels  by  col- 
lateral circulation.  Perilymphangitis  and  periphlebitis  may  occur  in 
tiie  cellular  tissue  around  the  thrombosed  lymphatics  and  veins.  This 
process  when  it  takes  place  in  the  parametria  is  pelvic  cellulitis,  a  dis- 
ease almost  forgotten  in  these  days  of  tubal  and  ovarian  pathology. 
See  Pelvic  Cellulitis. 

The  anatomical  changes  may  be  summarized  as  follows  : 

1.  Uterus   enlarged,  regular  in  outline,  and  of  doughy  or  soft 

consistence. 

2.  Congestion  extreme ;  there  may  be  extravasation  of  blood  in 

the  muscularis. 

3.  Endometrium  and  perimetrium  deeply  reddened  in  circum- 

scribed areas  throughout. 

4.  Small-cell   infiltration   of   interglandular    and    intermuscular 

connective  tissue, 

5.  Engorgement  of  lymph-vessels  and   excessive  secretion  from 

the  uterine  glands. 

The  milder  cases,  chiefly  characterized  by  engorgement,  increased 
secretion,  and  pain,  may  subside  in  a  few  days,  and  the  uterus  either 
may  become  normal  or  lapse  into  a  state  of  chronic  metritis.  In  the 
more  severe  forms  the  disease  may  run  a  destructive  course  to  the 
death  or  permanent  disability  of  the  patient,  and  will  in  extent  vary 
with  the  virulence  of  the  exciting  cause  and  the  resistance  of  the 
inflamed  structures.  Abscesses  rarely  develop  in  the  myometrium 
except  in  connection  with  myomata.  Inflammation  of  the  mucosa 
may  be  catarrhal,  suppurative,  ulcerative,  hemorrhagic,  or  all 
conjbined. 

A  grave  form  of  acute  disease  has  been  described  under  the  name 
diphtheritic  or  dissecting  metritis.^  The  infection  is  usually  puer- 
peral, but  is  sometimes  a  sequel  of  non-puerperal  diphtheria.  It  may 
be  associated  with  gangrene  of  the  vulva,  and  may  occur  after  scarlet 
fever,  typhoid  fever,  or  cholera.  In  puerperal  cases,  says  Garrigues, 
the  diphtheritic  infiltration  may  extend  from  the  endometrium  to  the 
neighborhood  of  the  peritoneum,  cutting  off  a  large  part  of  the  luus- 
cular  layer,  which  after  weeks  or  months  will  be  expelled  as  a  pear- 
shaped  body.  Dissecting  metritis  may  be  connected  with  similar 
disease  of  the  vulva  and  vagina. 

The  ultimate  possible  changes  which  may  follow  acute  metritis  in 
the  uterine  glands,  uterine  connective  tissue  and  muscularis,  and  in 
the  peritoneal  covering  of  the  uterus,  are  discussed  elsewhere.  See 
Chronic  Endometritis,  Chronic  Metritis,  and  Peritonitis. 

1  Garrigues,  "  Dissecting  Metritis,"  New  York  Medical  Journal,  1882,  vol.  xxxvi.p.  537;  Dis- 
eases of  Women. 

14 


210    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Symptomatology  of  Acute  Metritis. 

The  following  tabular  statement  embraces  the  principal  symptoms 
of  acute  metritis  : 

1.  Elevation  of  temperature  variable,  sometimes  preceded  by  a 

chill. 

2.  Pain,  commonly  confined  to  the  hypogastrium,  may  radiate  to 

the  back  or  thighs. 

3.  Painful  defecation  ;  rectal  tenesmus. 

4.  Frequent  and  painful  urination. 

5.  Nausea  ;  vomiting  and  constipation  usual. 

6.  Menses  suppressed  or  decreased  ;  occasionally  increased. 
The    symptoms  of   acute   metritis   depend   upon    the  extent  and 

gravity  of  the  disease,  and  therefore  may  vary  witliin  wide  limits 
from  those  of  a  mild  infection  to  those  of  the  greatest  virulence. 
An  apparently  mild  metritis  may,  however,  result  in  the  most  de- 
structive pelvic  infection  with  all  the  results  of  grave  peritonitis. 
The  onset  usually  is  marked  by  a  chill,  followed  by  variable  high 
temperature  and  pulse  ;  the  pain  is  often  intense.  There  is  usually 
tenesmus  of  the  rectum  and  bladder.  Menstruation,  if  present,  may 
cease  suddenly,  or  the  flow  may  increase.  The  menstrual  fluid  is 
mixed  with  the  secretions  of  the  inflamed  glands.  The  congestion 
often  passes  off  as  menorrhagia  comes  on.  This  is  nature's  way  of 
relieving  the  engorged  vessels.  Tlie  discharge,  especially  in  the  gon- 
orrhoeal  form,  may  become  rapidly  purulent.  When  the  inflamed 
uterus  contracts  to  expel  its  abundant  secretions  the  agony  is  that 
of  exaggerated  labor-pains.  Bearing-down  and  heat  in  the  pelvis 
are  often  excessive.  When  the  disease  has  extended  to  the  Fallo- 
pian tubes,  pelvic  connective  tissue,  ovaries,  and  especially  when  it 
invades  the  peritoneum,  there  may  be  grave,  even  fatal  toxaemia  with 
anxious  facies,  increased  vomiting,  and  tympanites. 

Diagnosis  of  Acute  Metritis. 

The  diagnosis  is  based  upon  the  changes  just  described,  which,  if 
present,  will  give  rise  to  the  following  physical  signs : 

1.  Tenderness   on   pressure   over  the   hypogastrium  and  in  the 

vaginal  fornix. 

2.  Abdominal  muscles  tense. 

3.  Vagina  dry  and  hot  to  the  touch. 

4.  Pathological  secretions  from  associated  endometritis. 

5.  Uterus  enlarged,  softened,  and  tender. 

Examination  is  often  so  painful  as  to  be  impracticable  without 
anaesthesia ;  the  os  uteri  is  usually  patulous,  and  often  surrounded  by 
erosion.  The  vagina  is  hot,  and  the  arteries  strongly  pulsating.  The 
urgent  necessity  is  to  w^atch  for  tubal  and  peritoneal  extension.  See 
Diagnosis  of  Salpingitis  and  Pelvic  Peritonitis.  The  mere  recogni- 
tion of  acute  metritis  is  wholly  inadequate.  Unless  the  state  of  the 
uterine  appendages  and  parametria  is  made  out  accurately,  thera- 
peutic  indications   of  the  greatest  urgency  may  be  overlooked  ;  one 


ACUTE  METRITIS.  211 

therefore  may  have  to  make  an  examination  under  anaesthesia  ;  as  the 
ease  progresses  repeated  examinations  may  be  necessary.  In  all  acute 
inflammations  of  the  genitals  the  use  of  the  sound  is  contraindicated 
strictly. 

Prognosis  of  Acute  Metritis. 

The  prognosis  of  acute  metritis  is  always  disquieting,  often  grave. 
The  disease  may  terminate  in  rapid  resolution  or  in  chronic  metritis. 
Extension  to  the  peritoneum  involves  immediate  danger  to  life  or 
remote  danger  to  health.  The  relative  virulence  of  different  mi- 
crobes has  been  discussed  in  the  paragraphs  on  Etiology.  Puerperal 
metritis  is  most  liable  to  spread  with  the  lymph-stream,  and  is, 
especially  when  due  to  streptococcus  pyogenes,  the  gravest  form ;  this 
form  even  when  early  recognized  and  promptly  treated  by  radical 
surgery  is  apt  to  result  fatally,  for  the  toxins  are  specially  deficient  in 
their  power  to  attract  leucocytes — that  is,  to  build  up  a  limiting  wall 
around  the  infected  centre  and  thereby  to  protect  the  general  system 
against  invasion.  For  this  reason  the  streptococcus  germ  may  reach 
the  uterus  in  an  hour ;  in  two  or  three  hours  more  it  may  have  passed 
far  beyond  the  uterus,  where  surgery  cannot  reach,  much  less  re- 
move, it. 

Treatment  of  Acute  Metritis. 

Future  bacteriological  researches  may  open  the  way  for  an  etio- 
logical classification  that  will  furnish  a  safe  and  definite  guide  to  the 
therapeutic  indications.  Work  in  this  direction  thus  far,  however, 
gives  little  promise  of  immediate  practical  results.  In  this  connection 
we  may  add  that  serum  therapy  is  undeveloped,  and  therefore,  in  a 
practical  sense,  is  not  very  pertinent  to  the  subject. 

The  treatment  is  not  very  satisfactory  ;  it  is  prophylactic,  abortive, 
palliative,  expectant,  and  surgical.  See  Treatment  of  Sepsis  in 
Chapter  YIII. 

Prophylaxis  includes  the  avoidance  or  removal  of  the  predispos- 
ing and  exciting  causes.  Reference  to  the  etiology  will  suggest  the 
appropriate  indications.  Susceptibility  is  greater  during  the  puerperal 
state,  parturition,  abortion,  and  menstruation.  Extra  care,  therefore, 
at  such  times  is  essential.  Especially  forbid  undue  exposure  of  all 
kinds.  Avoid  the  bacterial  exciting  causes  by  asepsis.  Aseptic  mid- 
wifery is  imperative.  The  minor  gynecological  and  obstetric  exam- 
inations and  manipulations  without  asepsis  are  dangerous.  Above  all, 
one  should  use  every  means  to  prevent  the  spread  of  a  vulvovaginitis, 
especially  if  it  be  gonorrhceal,  to  the  uterus.  See  Treatment  of 
Vulvovaginitis. 

The  Abortive  Treatment  is  applicable  only  in  the  onset,  and  in- 
cludes such  antiphlogistic  measures  as  may  cut  short  the  attack  during 
the  stage  of  congestion.  The  disease  once  established  must  run  its 
course.  A  large  blister  over  the  hypogastrium  may  be  useful.  Leeches 
are  of  great  value  if  early  and  thoroughly  applied.     Use  five  or  more 


212    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

over  each  inguinal  region  and  five  to  the  perineum — two  or  three  are 
useless.  The  ice-bag  over  the  hypogastriura  is  useful.  A  most  essential 
thing  is  early  and  active  catharsis  by  a  mercurial  purge,  two  grains 
of  calomel  or  five  of  blue  mass,  repeated  if  necessary,  and  followed 
by  Rochelle  salt  or  some  other  saline.  The  treatment  is  palli- 
ative and  expectant  in  the  milder  cases,  but  may  have  to  be  energetic 
in  the  more  virulent.  In  cases  of  metritis  following  plastic  gyneco- 
logical operations  the  sutures  should  be  removed  immediately  and  the 
denuded  surfaces  cauterized  with  pure  carbolic  acid. 

The  Palliative  Treatment  includes  rest  in  bed,  anodynes,  espe- 
cially the  opiates,  the  hot  or  warm  water  vaginal  douche — the  hot- 
water  bag,  and  the  hot  hip-pack.  When  the  acute  stage  is  subsiding 
there  may  be  use  for  the  glycerin  and  wool  vaginal  tamponade. 
Chapter  TV.  Later,  iodine  counterirritation  applied  to  the  hypo- 
gastrium  and  vaginal  fornix,  though  highly  recommended,  are  of 
doubtful  value.  Severe  pain  may  be  relieved  by  a  suppository  of 
aqueous  extract  of  opium,  one  grain,  and  extract  of  belladonna,  one- 
sixth  of  a  grain. 

Expectant  Treatment. — The  milder  self-limited  infections  which 
have  no  grave  svstemic  or  local  manifestations  may  be  dismissed  with 
palliative  or  expectant  treatment.  In  grave  infections  it  may  be 
extremely  difficult  or  impossible  to  choose  wisely  between  the  danger 
of  the  disease  and  the  extra  peril  of  surgical  interference  ;  hence,  even 
in  serious  cases,  the  expectant  course  may  be  the  part  of  wisdom. 

Surgical  Treatment. — When  the  systemic  condition  is  grave 
and  the  nervous  system  indicates  profound  toxaemia  the  disease 
under  any  treatment  will  in  a  large  proportion  of  cases  terminate 
fatally.  A  number  of  practical  and  momentous  questions  at  once 
arise  : 

Question  1.  Is  there  simple  absorption  into  the  circulation  from 
some  focus  of  decomposition  in  the  uterus  ?  Is  the  toxaemia  due  to 
the  products  of  a  decomposing  foreign  body,  such  as  a  blood-clot,  a 
fragment  of  placenta,  retained  membrane,  or  pent-up  lochia  ?  In 
other  words,  is  it  due  to  the  absorbed  products  of  putrefactive  bacteria  ? 
To  put  the  question  in  more  concise  form.  Is  it  saprsemia?  If  the 
ans^ver  be  in  the  affirmative,  the  indication  is  clear  and  imperative  to 
remove  the  putrefying  mass,  wash  out  the  endometrium,  and  establish 
drainage.  The  offending  mass  may  be  removed  with  the  finger,  the 
placental  forceps,  or,  if  necessary,  with  the  dull  curette,  or  if  the  ute- 
rine canal  is  open  it  may  be  wiped  out  with  a  swab  attached  to  a  long 
forceps.  Sharp  curettage,  powerful  cauterization,  and  all  other  severe 
surgical  measures  in  this  connection  are  unnecessary. 

Question  2.  Is  the  uterine  mucosa  the  seat  of  an  infection,  and 
as  such  is  it  the  distributing-point  of  bacteria  which  may  spread  and 
infect  the  uterine  appendages  and  peritoneum  ?  If  the  bacterial  in- 
vasion has  extended  beyond  the  uterus,  to  what  extent  are  the  uterine 
appendages  and  peritoneum  invaded?  Is  the  systemic  disturbance 
such  as  to  suggest  that  the  bacteria  and  their  products  are  very  liable 
to  enter  the  general  circulation  in  quantities  sufficient  to  give  rise  to 
pronounced  septicaemia  ? 


ACUTE  METRITIS.  213 

Question  3.  Have  pus  emboli  been  carried  through  the  circulation 
from  one  focus  of  suppuration  to  set  up  other  foci  in  different  parts  of 
the  body,  and  thereby  produce  metastatic  abscesses  ?  To  put  the  ques- 
tion in  another  form,  Is  there  pyaemia  ? 

If  the  answers  to  the  second  and  third  queries  are  in  the  affirma- 
tive, it  becomes  essential  to  decide  whether  the  infection  has  spread  so 
far  beyond  the  uterus  as  to  make  the  metritis  relatively  insignificant. 
Clearly,  if  there  are  metastatic  abscesses,  or  if  even  infection  has 
spread  to  the  other  pelvic  organs,  surgical  treatment  of  the  intra- 
uterine infection  alone  would  be  useless  and  might  add  to  the  danger. 
Abdominal  or  vaginal  section  and  the  drainage  of  the  abscesses,  or 
even  removal  of  the  uterus  and  its  appendages,  w^ould  then  have  to  be 
considered. 

The  milder  cases,  as  already  stated,  may  safely  be  left  to  palliative 
and  expectant  treatment.  The  graver  infections  unfortunately  have 
in  the  majority  of  cases  passed  beyond  the  range  of  intra-uterine  thera- 
peutics before  the  question  of  operative  interference  is  forced  upon  the 
surgeon.  We  may,  however,  be  concerned  with  the  question,  What 
surgical  measures,  if  any,  are  justifiable  in  the  effort  to  prevent  the 
further  spread  of  dangerous  acute  uterine  infection  which  still  is  con- 
fined nearly  or  quite  to  the  uterus  ? 

If  dilatation,  curettage,  and  drainage  are  to  be  invoked,  the  choice 
of  method  at  once  becomes  important.  In  this  consideration  let  us 
not  lose  sight  of  the  purpose  of  these  procedures  :  it  is  to  cut  short 
and  prevent  the  extension  of  uterine  infection  ;  or,  if  already  in  a 
degree  extended,  to  limit  its  force  by  withdrawing  the  toxic  supply. 
Partial,  inefficient  curettage,  which  opens  up  lymphatics  and  veins  to 
fresh  infection,  but  does  not  remove  all  the  infected  mucosa,  will  pre- 
pare the  ^vay  for  further  infection,  which  may  be  more  virulent  and 
more  sweeping  than  the  first;  as  tersely  stated  by  de  Lee,  such  a  pro- 
cedure is  like  raking  a  patch  of  lawn  after  scattering  seed  over  it — a 
veritable  insemination.  It  is  evident,  therefore,  that  curettage,  if  in- 
dicated at  all,  should  be  thorough  ;  should,  indeed,  stop  at  nothing 
short  of  the  removal  of  the  entire  infected  mucosa.  The  sharp  curette, 
which  generally  has  been  considered  a  more  dangerous  instrument 
than  the  dull  one,  is  then  less  dangerous.  The  operations  reported 
by  Pryor,  Krug,  and  others,  indeed  prove  that  the  sharp  curette  in 
careful  hands  is  much  less  dangerous  than  has  been  supposed.  The 
thorough  application  of  it  in  selected  cases  has,  according  to  reliable 
report,  been  followed  by  prompt  decrease  in  the  toxaemia  and  in  the 
other  grave  symptoms.  The  opponents  of  the  operation  declare,  not 
without  reason,  however,  that  most  of  the  recoveries  would  have 
occurred  without  it,  and  that  many  of  the  failures  have  occurred  in 
consequence  of  it.  In  the  present  state  of  our  ignorance  on  this  per- 
plexing subject,  suspension  of  judgment  and  expectancy  are  perhaps 
more  rational  than  dogmatic  assertion  or  radical  measures. 

If  the  infected  endometrium  has  become  soft,  spongy,  friable,  and 
macerated,  and  if  it  is  decided  that  thorough  curettage  will  lessen  the 
danger  of  the  extension  of  the  infection,  the  steps  of  the  operation 
will  be  as  follows  : 


214    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

1.  Anaesthesia. 

2.  Preparation  of  the  vagina  and  external  genitalia  as  directed 

for  minor  operations  in  Chapter  II. 

3.  Dilatation  of  the  uterus,  unless  it  is  already  sufficiently  open. 

4.  Curettage  of  the  infected  endometrium  by  means  of  the  sharp 

curette ;  see  Curettage,  Chapter  V. 

5.  Thorough  irrigation   of   the  endometrium  with  hot  sterilized 

water. 

6.  Tliorough    mopping   out  of  the    endometrium    with  cotton 

wound  on  dressing-forceps,  and  dipped  in  a  saturated  solu- 
tion of  iodine  crystals  with  pure  carbolic  acid. 

7.  Placing  of  an  antiseptic  dressing  over  the  vulva. 

Some  operators  omit  the  iodine  and  carbolic  acid  applications  and 
rely  upon  the  thoroughness  of  the  curettage  to  remove  all  infectious 
matter.  An  advantage,  however,  in  the  use  of  this  powerful  disin- 
fectant lies  in  the  fact  that  it  insures  thorough  disinfection  of  any 
infected  shreds  which  may  have  escaped  the  curette,  and  that  by  its 
cauterizing  effect  it  so  shuts  the  mouths  of  the  freshly  opeued  lymph- 
vessels  and  blood-vessels  that  further  absorption  through  them  is  less 
likely  to  occur. 

It  is  the  custom  of  many  excellent  operators  after  curettage  to 
tampon  the  endometrium  lightly  with  a  continuous  strip  of  antiseptic 
gauze,  and  to  fill  the  vagina  with  another  strip  somewhat  wider ;  after 
twenty-four  hours  they  remove  the  gauze,  repeat  the  intra-uterine 
irrigation,  and  introduce  fresh  gauze.  Ansesthesia  now  is  not  usually 
required.  Before  the  introduction  of  the  gauze  it  is  well  to  make  a 
thorough  intra-uterine  application  of  creolin  or  of  a  25  per  cent,  solution 
of  ichthyolate  of  ammonium  in  glycerin.  It  is  a  mistake  to  saturate 
the  gauze  with  such  medicinal  substances,  because  they  interfere  with 
its  chief  function — capillary  drainage^  Iodoform  and  sublimated 
gauze  have  caused  dangerous  poisoning,  and,  therefore,  should  not  be 
used  in  large  quantities.  If  the  grave  symptoms  have  subsided,  the 
gauze  may  be  removed  at  the  end  of  twenty-four  hours,  and  need  not 
be  renewed.  In  very  infectious  cases  some  operators  renew  the  gauze 
and  irrigate  with  hydrogen  dioxide  daily  until  the  uterine  secretions 
become  normal.  See  Treatment  of  Chronic  Endometritis,  Chapter 
XVII.,  for  a  further  discussion  of  intra-uterine  curettage  and 
drainao^e. 

The  operation  given  above  is  less  dangerous  and  more  rational  than 
the  meddlesome  half-way  measures  of  intra-uterine  medication  and 
irrigation  of  the  undilated  septic  uterus.  The  judicious  selection  of 
cases  is  manifestly  a  matter  of  great  difficulty.  If  proper  selection 
can  be  made,  the  operation  in  careful  hands  may  be  permissible  and 
useful. 

The  writer's  personal  conviction  of  the  value  of  dilatation,  curet- 
tage, and  drainage  of  the  endometrium  in  acute  infection  is  that  the 
measure  should  be  limited  in  its  application.  Let  no  man  be  lured  to 
the  performance  of  this  dangerous  operation  in  an  acute  case  because 
of  the  ease,  safety,  and  efficacy  of  the  similar  procedure  in  chronic 
endometritis.     The  only  cases  in  which  it  should  be  performed  are 


ACUTE  METRITIS.  215 

those  which  otherwise  will  result  in  dangerous  spreading  of  the 
infection. 

Clearly  curettage  manifestly  is  contraindicated  in  the  numerous 
and  grave  cases  in  which  the  infection  has  passed  to  the  parametria, 
not  from  the  endometrium,  but  by  the  lymph-vessels  or  blood-vessels. 

All  admit  the  practical  difficulty,  not  to  say  impossibility,  of  selec- 
tion so  as  to  limit  the  operation  to  those  infections  which  are  really 
dangerous  and  still  confined  to  the  uterus.  It  is,  moreover,  a  serious 
question  whether  the  course  of  grave  puerperal,  gonorrhoeal,  or  trau- 
matic infection  often  is  arrested  by  the  procedure.  At  the  same  time 
few  will  deny  that  the  operation  repeatedly  has  given  rise  to  fatal 
results.  On  the  other  hand,  expectancy  and  palliation  will  often  be 
rewarded  by  the  subsidence  of  grave  symptoms  and  by  final  recovery. 
There  can  be,  moreover,  for  a  surgeon  no  greater  cause  of  regret  than 
the  fact  that  he  has  exhausted  the  resisting  forces  of  his  patient  by  a 
dangerous  half-way  measure  which  itself  may  have  contributed  to  the 
necessity  for  a  more  radical  operation,  and  that  while  with  the  prom- 
ise of  such  a  measure  he  has  been  lulling  himself  into  a  sense  of  false 
security  the  infection  has  gained  irresistible  force.  If  urgent  indica- 
tions arise,  the  best  hope  of  recovery  may  be  in  abdominal  or  vaginal 
section  and  drainage,  or  the  removal  of  the  uterus  together  with 
its  appendages.  These  oj^erations,  if  indicated  at  all,  are  made 
necessary  by  the  rapid  spread  of  the  infective  process  and  therefore 
become  at  once  imperative.  Until  the  necessity  for  such  extreme 
measures  becomes  apparent,  there  is  at  least  virtue  in  the  attitude 
of  watchful  expectancy.  See  Vaginal  Incision  and  Drainage,  in 
Chapter  XXIII. 

Treatment  of  Puerperal  Metritis. — Much  of  seeming  plausibil- 
ity has  been  written  about  the  treatment  of  puerperal  infection  of  the 
uterus  and  adjacent  organs,  but  from  the  standpoint  of  scientific  exact- 
ness it  is  all  unsatisfactory  and  leaves  us  still  on  the  low  plane  of 
empiricism.  When  called  to  a  case  of  puerperal  infection  in  the  first 
two  or  three  days  of  the  disease  the  author  frequently  has  made  use 
of  the  following  procedures  with  good  results  : 

1 .  Careful  bimanual  palpation,  using  rubber  gloves,  with  or  with- 
out anaesthesia,  as  the  case  may  require. 

2.  If  there  are  no  gross  lesions  of  the  uterine  appendages  nor 
accumulations  of  pus  in  the  pelvis  to  require  a  radical  operation,  the 
patient  is  placed  on  a  table  or  across  the  bed  with  the  buttocks  well 
over  the  edge  of  the  bed. 

3.  The  vagina  and  cervix  uteri  are  exposed  with  a  Simon  speculum 
and  the  anterior  and  posterior  lips  of  the  cervix  are  grasped  with  flat 
vulsellum  forceps  and  the  cervix  drawn  toward  the  vulva. 

4.  With  the  uterus  held  steady  the  entire  endometrium  is  ^\iped 
out  (curetted  as  it  were)  by  means  of  a  wad  of  gauze,  attached  to  a 
long  forceps,  in  order  to  remove  any  fragment  of  placenta,  membranes, 
blood-clots,  or  secretions. 

5.  The  endometrium  after  irrigation  with  a  1  :  5000  solution 
of  formalin  or  some  other  disinfectant,  is  swabbed  out  (using  fresh 
gauze  on  the  forceps)  with  a  10  per  cent,  solution  of  creolin  or  some 


216    INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS. 

other  disinfectant,  to  be  followed  by  the  introduction  to  the  endome- 
triam  of  a  half  ounce  of  Crede's  ointment  of  argentum  colloidale. 
Thereafter  the  uterus  is  not  invaded  again  unless  some  special  indica- 
tion arises. 

6.  One  drachm  of  Crede's  ointment  may  be  rubbed  in  thoroughly 
for  twenty  minutes  each  day  over  the  abdomen  or  back. 

7.  The  intravenous  injection  of  15  grains  of  a  2  per  cent,  emul- 
sion of  argentum  colloidale,  once  a  day,  is  a  recent  and  promising 
therapeutic  resource. 

8.  If  the  infection  is  probably  or  certainly  of  streptococcic  origin, 
the  antistreptococcus  serum  may  be  used  hypodermically  10-40  c.c. 
a  day. 

9.  The  bowels  should  be  opened  with  mercurials  and  salines,  or 
with  a  soft  capsule  containing  two  drachms  of  castor  oil  and  one-half 
drop  of  croton  oil. 

10.  The  author  frequently  has  seen  gratifying  results  from  the  free 
use  of  rum  and  milk,  twelve  ounces  of  rum  and  a  quart  of  milk  daily, 
given  in  divided  doses  at  intervals  of  one  or  two  hours. 


CHAPTER   XV. 

CHRONIC  ENDOCERVICITIS. 

The  synonyms  of  endocervicitis  are  cervical  catarrh  and  cervical 
endometritis.  Since  the  endometrium  is  situated  entirely  above  the 
internal  os,  there  is  a  manifest  impropriety  in  using  the  word  endo- 
metritis in  connection  with  the  cervix  uteri. 

In  studying  this  subject  the  reader  should  have  constantly  in  mind 
the  physiological  and  pathological  unity  of  the  reproductive  organs. 
Infection  seldom  is  confined  to  a  single  part  of  the  uterus ;  on  the 
contrary,  it  extends  usually  to  oth«r  parts  and  commonly  spreads 
to  adjacent  organs.  We  are  considering  nothing  less  than  the 
whole  subject  of  metritis,  but  with  special  reference  to  the  cervical 
mucosa. 

The  single  layer  of  columnar  epithelium,  the  underlying  connective 
tissue,  the  lymph-spaces,  the  lymphatics,  the  veins,  the  arteries,  and 
the  nerves  which  make  up  the  intracervical  mucosa,  are  suljject  to 
certain  chronic  changes  which  are  known  under  the  name  chronic 
endocervicitis.  Similar  disease  of  the  corporeal  mucosa  is  called  chronic 
endometritis. 

Etiology  of  Endocervicitis. 

Endocervicitis  is  inflammation  of  the  cervical  mucosa.  The  pre- 
disposing systemic  and  local  causes  and  the  bacterial  exciting  causes 
have  been  pointed  out  in  Chapter  X. 

The  disease  is  in  some  respects  like,  in  others  unlike,  corporeal 
endometritis.  It  often  occurs  by  extension  from  vulvovaginitis.  It 
rarely  descends  from  the  corpus  uteri.  It  may  have  been  carried  as 
a  primary  infection,  without  intermediate  infection  of  the  vulva  or 
vagina,  direct  to  the  cervical  mucosa.  As  in  the  corpus,  it  may 
involve  not  only  the  mucosa,  but  also  the  muscularis. 

Although  the  normal  endometrium  is  free  from  pathogenic  bacteria, 
the  cervical  cavity  is  quite  accessible  to  them.  This  explains  the 
greater  tendency  of  the  cervix  at  all  times,  especially  upon  slight  trau- 
matisms, to  become  infected.  The  cervical  glands,  M'ell  adapted  to 
receive,  retain,  and  distribute  infection,  easily  become  a  culture-ground 
for  bacteria.  Once  intrenched  in  the  gland-crypts,  the  germs  may 
remain  relatively  quiescent  for  long  periods,  and  then  may  develop 
new  cultures  and  spread. 

Among  the  more  frequent  predisposing  causes  of  endocervicitis  are 
the  following  : 

Puerperal  laceration  of  the  cervix. 

Excessive  coitus. 

Foreign  bodies,  tumors,  polypi. 

217 


218    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

The  Exciting  Causes  are  bacteria,  especially  gonorrhoeal,  which 
may  reach  the  cervix  direct  or  be  carried  by  extension  from  the 
v-ulvovagina  or  endometrium. 


Sequence  and  Patholo^  of  Endocervicitis. 

The  pathological  sequence  of  a  seemingly  insignificant  infection  of 
the  cervix  uteri,,  especially  if  acute,  may  be  either  by  continuity  of 
surface  to  endometritis,  salpingitis,  peritonitis,  and  ovaritis ;  or  by  the 

FiGrEE  86. 


A,  mucous  polypi  of  the  cervix  uteri— follicular  hypertrophy.  One  polypus  has  been  seized 
with  forceps  and  is  being  removed  with  scissors.  B,  small  mucous  polypi  hanging  out  of  the 
cervix  uteri ;  C,  mucous  polypi  being  removed  from  the  cervical  canal  with  the  sharp  curette. 

pelvic  lymphatics  and  veins  to  pelvic  lymphangitis,  phlebitis,  peri- 
tonitis, and  ovaritis  :  thus  acute  infection  seldom  is  confined  to  the 
cervix,  but  is  apt  to  involve  the  other  parts  of  the  uterus.  The 
corpus  uteri  and  adjacent  organs  are  more  likely  to  be  involved  if  the 
chronic  cervicitis  has  followed  an  acute  inflammation  ;  less  likely  if 
it  was  chronic  from  the  beginning. 

The  swollen   mucosa,  especially  if  the  cervix   be  lacerated,  takes 


CHRONIC  ENDOCERVICITIS.  219 

the  direction  of  least  resistance,  and  may  protrude  through  the  os 
externum.  The  thickened  everted  mucous  membrane  may  give  to 
the  cervix  the  appearance  of  great  enlargement.  The  condition  is 
not  unlike  that  of  the  prolapsed  hemorrhoidal  anus.  The  engorged 
open  cervical  glands  in  great  numbers  pour  out  their  secretion  upon 
the  vulvovaginal  surface.  The  discharge,  unlike  that  of  endometritis, 
is  thick,  ropy,  viscid,  abundant,  and  gelatinous.  It  may  be  dislodged 
only  with  difficulty  from  its  anchorage  in  the  cervical  glands. 

In  nullipara  the  internal  and  external  ora  are  sometimes  so  con- 
stricted as  to  cause  retention  of  the  cervical  secretions  and  consequent 
dilatation  of  the  cervical  cavity.     See  Figures  93  and  94. 

The  chief  pathological  factors  are  erosion  of  epithelium  and  glandu- 
lar enlargement.  In  this  respect  endocervicitis  offers  a  close  analogy 
to  corporeal  endometritis. 

Erosion  of  the  Cervical  Epithelium. — Erosion  of  the  cervix  is 
characterized  by  a  red  or  purple,  livid  color,  is  confined  usually  to  the 
area  immediately  around  the  external  os  uteri,  and  not  infrequently 
extends  over  the  entire  vaginal  portion  of  the  cervix ;  it  has  the 
appearance  of  ulceration,  and  in  the  older  literature  was  so  called. 
The  aflPected  area,  as  first  demonstrated  microscopically  by  Ruge  and 
Veit,  is  covered  by  a  layer  of  newly  formed  inflamed  epithelium. 
The  epithelium  is  not  destroyed  as  in  ulceration,  but  simply  is  eroded, 
and  forms  a  mucous  patch.  Ulcerative  processes — localized  necrosis 
— have  nothing  in  common  with  this  condition  ;  ulceration  is  the 
destruction  of  the  superficial  epithelium  and  inflammatory  involve- 
ment of  the  underlying  tissue,  and  as  compared  with  erosion  is  very 
rare.     Two  varieties  of  erosion  of  the  cervix  have  been  described  : 

1.  Simple  erosion. 

2.  Papillary  erosion — cock's-comb  granulations. 

1.  Simple  Erosion,  which  answers  to  the  description  given  in  the 
preceding  paragraph,  presents  a  smooth,  uniform,  velvety  surface, 
with  little  or  no  formation  of  new  glands,  and,  although  having  the 
appearance  of  ulceration,  shows,  on  microscopical  examination,  tlie 
characteristic  non-specific  mucous  patches  covered  by  a  single  layer 
of  newly  formed  epithelium. 

2.  Papillary  Erosion. — This  form  of  erosion,  from  its  livid,  red 
color  and  characteristic  projections,  has  been  called  cock's-comb  granu- 
lation. The  irregularity  of  surface  is  due  {a)  to  newly  formed  glands; 
(6)  to  hyperplasia  of  the  connective  tissue  beneath  the  surface  epithe- 
lium and  the  glands ;  (c)  to  elevations  of  the  interglandular  surfaces. 
The  surface,  as  in  simple  erosion,  is  covered  by  a  single  layer  of  col- 
umnar epithelium.  The  papillary  projections  in  gross  appearance 
may  resemble  closely  early  cancer,  but,  unlike  that  growth,  are  non- 
friable  and  have  little  disposition  to  bleed  on  handling.  There  is 
abundant  small  round-cell  infiltration  of  the  connective  tissue  and  free 
secretion  of  mucus. 

Glandular  Enlargement  occurs  in  two  forms  : 

1.  Polypoid  glandular  enlargement — mucous  polypi. 

2.  Cystic    glandular   enlargement — cystic    degeneration — some- 

times called  follicular  erosion,  sometimes  ovula  Nabothi. 


220    INFECTIONS,   INFLAMMATIONS,   AND   ALLIED  DISORDERS. 

1.  The  Polypoid  Glandular  Enlargement  produces  diminutive  mucous 
polypi,  smaller,  of  different  origin,  and  softer  than  fibrous  polypi.  The 
genesis  of  mucous  polypi  is  as  follows :  The  enlarged  glands  protrude 
upon  the  surface ;  their  mouths  become  obliterated ;  the  glandular 
tissue  is  (Edematous  from  retained  secretions ;  the  bases  constrict  and 
the  little  masses  become  polypoid ;  they  correspond  to  the  so-called 
adenoids  of  nasal  pathology.  A  similar  development  sometimes  occurs 
in  the  endometrium  as  the  result  of  endometritis.  These  mucous 
polypi,  although  the  result  of  inflammation,  are  classified  as  benign 
adenoma  by  some  pathologists. 

2.  Cystic  Glandular  Enlargement — Follicular  Erosion. — Very  often 
as  the  result  of  erosion  the  openings  of  the  cervical  glands  become 
occluded  by  adhesive  inflammation,  so  that  the  glands  are  distended 
by  their  own  secretions.  This  process,  known  as  cystic  degeneration, 
results  in  the  formation  of  numerous  round  submucous  bodies,  some- 
times called  ovula  Xabothi,  but  more  commonly  known  as  follicular 
cvsts  or  retention-cysts  ;  they  may  be  present  in  number  from  one  to 
several  hundred  ;  they  are  hard,  tense,  spheroidal  bodies,  varying  in 
size  from  that  of  a  millet-seed  to  that  of  a  pigeon's  egg ;  and  on  digital 
touch  if  small  feel  like  shot  under  the  skin.  Seen  through  the 
speculum,  they  appear  as  rounded  elevations  of  yellow,  blue,  or  gray 
color ;  they  contain  inspissated  mucus,  which  sometimes  is  infected  by 
pus  micro-organisms,  forming  small  circumscribed  abscesses.  These 
cysts  when  small  are  lined  with  the  typical  gland  epithelium  of  the 
cervix,  but  as  they  become  distended  the  epithelium  flattens  and 
finally  disappears  through  pressure  atrophy.  Cystic  degeneration, 
according  to  Emmet,  is  a  cause  of  numerous  reflex  nervous  disturb- 
ances ;  it  rarely  is  seen  on  the  nulliparous  cervix,  but  is  a  frequent 
result  of  laceration,  and  as  such  will  be  described  further  in  the 
chapter  on  that  subject. 

Symptoms  of  Endocervicitis. 

Endocervicitis  may  cause  no  characteristic  symptoms.  The  symp- 
toms associated  with  it  may  be  due  to  complications,  and  therefore 
have  little  or  no  diagnostic  value ;  among  them  are  disordered  men- 
struation, sterility,  pain  in  the  back,  a  sense  of  weight  in  the  pelvis, 
and  functional  disturbances  of  extrapelvic  organs,  especially  the 
organs  of  digestion. 

Diagnosis  of  Endocervicitis. 

The  diagnosis  is  simplified  by  the  accessibility  of  the  diseased 
structures,  especially  when  the  inflamed  swollen  mucosa  is  rolled  out 
in  contact  with  the  vagina  and  when  the  erosion  extends  out  over  the 
external  os ;  it  must  depend  upon  the  physical  signs,  upon  micro- 
scopical examination  of  tissues,  and  upon  examination  of  the  secretions. 

Digital  and  Sight  Examination. — Lacerations  and  cystic  gland- 
ular enlargement  are  examined  better  by  digital  touch  than  by  sight. 
Erosions  and  mucous  polypi  are  soft  and  elusive,  and  therefore  are 
seen  better  than  felt. 


CHRONIC  ENDOCEBVWITIS.  221 

Speculum  Examination. — The  speculum,  Sims'  speculum  pre- 
ferred, will  disclose  some  or  all  of  the  following  conditions  if  they 
exist  outside  the  external  os  : 

1.  Margins  and  scars  of  lacerations. 

2.  Retention-cysts — rounded  yellowish  or  bluish  projections. 

3.  Mucous  polypi,  protruding  from  the  external  os. 

4.  Erosions,  as  described  under  pathology. 

5.  External  os  filled  with  a  plug  of  tenacious  mucus  or  mucopus. 

6.  Ulcerations,  which  are  seen  rarely  except  those  of  malignant, 

tubercular,  or  cancerous  origin. 

Examination  of  Secretions. — The  secretion  is  always  abundant 
and  viscid,  and  is  usually  clear,  but  may  be  murky  from  the  admixt- 
ure of  epithelium  and  leucocytes ;  it  may  also  be  yellow  or  greenish 
yellow  from  the  presence  of  pus,  or  red  from  streaks  of  blood. 

To  obtain  secretions  for  bacteriological  examination  for  gonococci, 
tubercle  bacilli,  or  other  organisms,  the  method  of  Schultze  may  be 
employed,  as  follows  : 

1.  Sterilize  the  vagina  Avith  douches. 

2.  Place  a  sterile  cotton  tampon  against  the  cervix  uteri. 

3.  On  the  day  following  remove  the  tampon,  collect  the  secretions 

with  a  swab,  and  examine  immediately. 

The  early  differential  diagnosis  of  erosions,  both  simple  and  papil- 
lary, from  carcinoma  is  most  important.  Friability  and  bleeding 
upon  handling  with  fingers  or  instruments  are  the  two  most  reliable 
clinical  signs  of  carcinoma  as  distinguished  from  erosions.  The 
symptoms  are  not  to  be  relied  upon,  because  erosions  may  give  all  of 
the  typical  signs  of  carcinoma,  and  beginning  carcinoma  may  give 
rise  to  few  or  no  signs.  For  an  absolute  diagnosis  a  microscopical 
examination  should  be  made  of  an  excised  part  of  the  suspected 
growth.  See  Differential  Diagnosis  in  Chapter  XXYIII.  on  Car- 
cinoma Uteri. 

Ulceration  of  the  Cervix  may  be  related  closely  to  endocervi- 
citis.     The  following  varieties  of  ulcer  are  recognized  : 

1.  Decubitus  ulcer,  caused  by  ill-fitting  pessaries  and  friction,  as 

in  procidentia  uteri. 

2.  Carcinomatous  ulcer. 
.    3.  Tubercular  ulcer. 

4.  Chancre  and  chancroid. 

As  compared  with  erosion  and  glandular  enlargement,  ulceration 
is  rare.  The  causes,  pathology,  and  diagnosis  are  the  same  as  for 
similar  conditions  in  other  parts  of  the  body. 

Treatment  of  Endocervicitis. 

In  the  treatment  of  cervicitis  it  is  M'ell  to  remember  the  physio- 
logical fact  that  irritation  at  the  opening  of  a  duct  will  stimulate  and 
increase  the  secretion  of  the  gland  or  glands  from  which  the  duct 
leads ;  and,  conversely,  withdrawal  of  the  irritation  Avill  cause  a 
decrease  in  the  secretion.  The  same  is  pathologically  true  of  the 
uterine  canal  and  the  uterine  glands.     The  irritation  caused  by  endo- 


222    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

cervicitis  may  increase  uterine  secretions.  Whatever  will  allay  irrita- 
tion of  the  cervix  must  tend  to  relieve  the  excessive  glandular  activity. 

In  acute  or  recent  endocervicitis  the  treatment,  especially  if  the 
infection  be  gonorrhoeal,  should  be  strongly  disinfectant.  The  pur- 
pose is  to  prevent  extension  to  the  corpus  uteri  and  parametria.  First, 
clean  out  the  mucous  plug,  then  thoroughly  apply  a  saturated  solution 
of  iodine  in  95  per  cent,  carbolic  acid  over  the  whole  intracervical 
mucosa.  The  strong  tendency  of  the  infection  to  spread,  and  the 
consequent  danger  of  the  disease  being  carried  to  the  corporeal  endo- 
metrium by  the  careless  introduction  of  instruments  past  the  internal 
OS,  should  be  kept  constantly  in  mind. 

When  the  chronic  disease-process  has  penetrated  to  the  deep  mucous 
folds  and  glandular  pockets,  superficial  treatment  will  fail.  It  then 
becomes  necessary  to  destroy  the  infected  mucosa.  Deeply  acting 
caustics  may  accomplish  this,  but  the  resulting  cicatricial  contraction, 
especially  when  the  canal  is  not  very  patulous,  contraindicates  their 
use.  The  same  objection  in  less  degree  applies  to  removal  of  the 
mucosa  by  sharp  curettage.  Thorough  excision  and  covering  by  a 
plastic  operation  the  surfaces  thereby  exposed  are  usually  the  best 
treatment.  The  operation  of  Schroeder,  which  fulfils  this  indication,  is 
performed  as  follows  : 

Schroeder's  Operation. — The  patient  being  under  anaesthesia  and 
in  Sims'  lateroprone  position,  the  cervix  exposed  by  Sims'  or  Simon's 

Figure  87. 


Figure  88. 

M 

% 

Ml 

"^isS^l^^ 

S  '^     w  )^ 

"^B 

|^r;^| 

Jf^ 

^PBh  1  l 

^P 

l^/LI  r 

iP^I 

A       iXSl 

/ 

Figure  ST.— Scbruetkr's  operation,  first  step.  Lateral  divi.sion  of  the  cervix  uteri  with 
straight  scissors.  Posterior  lip  of  cervix  held  with  fiat  vulsellum  forceps.  Dorsal  position. 
Simon  speculum. 

FiGUEE  88.— Schroeder's  operation,  second  step.  Removal  of  diseased  cervical  mucosa, 
preparatory  to  folding  each  cervical  flap  upon  itself. 


speculum   is  drawn  toward  the  vulva  and  divided  bilaterally  with 
scissors  to  or  beyond  the  uterovaginal  junction.     The  anterior  and 


CHRONIC  ENDOCERVICITIS. 
Figure  89.  Figure  90. 


223 


/' ""._ 

^H^^^B^^^^MM  V     1 

m 

^^^^HS^^^^^^H    '' 

i 

§ 

f 

Hif 

Figure  91. 


Figure  89.-Schroeder's  operation,  third  step.  Cut  margin  of  the  vaginal  Portion  of  the 
cervix  uteri  united  with  the  cut  margin  of  the  intracervical  canal  at  the  ?n?Je  o///)^  vs  mind^ 
Three  sutures  in  place  and  tied  on  the  anterior  lip.    Middle  suture  passed  but  not  tied  on  the 

^°^  FiGURE^ob.— Schroeder's  operation,  fourth  step.  Lateral  denudation  of  the  cervix  uteri 
precisely  as  it  would  be  done  in  trachelorrhaphy.    This  is  preparatory  to  the  introduction  oi 

°  FiCTEElsL-Sc^hroeder's  operation,  fifth  step.  All  the  sutures  introduced  and  tied  on  one 
side  thereby  rolling  in  the  expo.sed  cervical  mucosa,  the  first  suture  being  introduced  on  the 
other  side.   When  all  the  required  sutures  have  been  introduced  and  tied  the  operation  will 

^  F^wTOili^.-Schroeder's  operation,  complete.  The  sutures  in  the  cervical  canal  have  been 
rolled  in  and  are  almost  out  of  sight,  only  the  ends  showing.  Each  side  of  the  cervix  uttn 
has  been  brought  together  by  means  of  four  interrupted  sutures. 

posterior  lips  are  then  separated  widely  with  tenacula.  The  condition 
is  now  like  that  of  extensive  bilateral  laceration  of  the  cervix.  The 
lateral  incision  should  be  deep  enough  so  that  when  the  lips  are  forced 
apart  all  the  diseased  intracervical  mucosa  may  be  exposed  and  excised. 


224    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

The  anterior  and  posterior  flaps  are  now  turned  in  each  upon  itself 
and  united  with  sutures  to  the  intracervical  margins  of  the  wound. 
Two  or  three  sutures  are  required  to  secure  each  flap.  The  lateral 
incisions,  now  much  shortened  by  the  folding  in  of  the  flaps,  may  after 
suitable  denudation  be  closed  by  suture,  as  in  Emmet's  operation  for 
laceration  of  the  cervix.  Upon  completion  of  the  operation  the  flap 
sutures  will  be  situated  deep  in  the  cervical  canal,  where  removal  of 
them  would  be  difficult.  They  should  therefore  be  of  catgut.  The 
lateral  sutures  should  be  of  silkworm  gut  or  chromic  catgut.  If  silk- 
worm gut,  they  should  be  removed  in  about  two  weeks.  The  opera- 
tion, if  well  done,  is  followed  by  permanent  cure  and  freedom  from 
stenosis.  Great  eversion  through  the  os  externum,  giving  theoutrolled 
mucosa  an  ulcerated  appearance,  is  .due  usually  to  laceration  of  the 
cervix,  and  should  be  treated  as  such.  See  Emmet's  Operation.  In 
rare  cases  pronounced  eversion  and  erosion  occur  in  the  virgin  cervix, 
giving  rise  to  soft,  spougy,  granular  masses,  which  should  be  removed 
with  curved  scissors,  the  cut  surfaces  cauterized,  and  the  cervix  dressed 
with  strips  of  gauze  saturated  with  a  mixture  of  10  per  cent,  ammo- 
niated  ichthyol  in  glycerin  ;  the  dressings  to  be  changed  daily  until 
the  surflices  have  healed.  This  treatment  will  be  disappointing  if 
there  be  extensive  endometritis  above,  unless  that  also  be  included  in 
the  plan  of  treatment.  See  Treatment  of  Endometritis.  It  may, 
however,  be  wholly  satisfactory  if  the  inflammation  is  confined  essen- 
tially to  the  lower  cervical  mucosa.  If  it  fails,  Schroeder's  operation  is 
indicated. 


Figure  93. 


Figure  94. 


Fig  L-RE  93.— Cervical  canal  distended  by  secretions.  This  is  due  to  obstruction  at  the  in- 
ternal OS  uteri  and  partial  or  complete  closure  of  the  external  os.  Such  obstruction  and 
closure  are  frequentlv  consequent  upon  cicatricial  contraction  following  cauterization. 

Figure  94.— Pinhole  os  of  congenital  origin  in  a  partially  developed  uterus  :  A,  shovi's  the 
pinhole  os  in  section  ;  B,  shows  the  pinhole  os  as  seen  through  the  speculum. 


Polypoid  endocervicitis,  so  called,  requires  the  removal  of  the  aden- 
oid growths  by  means  of  the  sharp  curette  or  the  scissors.  When 
glandular  disease  is  extensive,  it  may  be  necessary  to  perform  Schroe- 
der's operation. 


CHRONIC  ENDOCERVITIS.  225 

Pinhole  Os. — In  nulliparae  the  internal  and  external  ora  are  some- 
times so  narrow  that  the  cervical  secretions  are  retained  and  distend 
the  cervical  cavity  quite  beyond  its  normal  size.  Sometimes  the  inter- 
nal OS  is  open,  and  the  corpus  is  enlarged  correspondingly  from  the 
same  cause.  The  retained  secretions  give  rise  to  great  irritation  and 
reflex  disturbances.  The  rational  treatment  is  to  open  the  canal  by 
free  incision  of  the  external  os,  and,  if  necessary,  by  dilatation  of  the 
internal  os.  Exploratory  curettage  will  show  whether  the  endome- 
trium requires  thorough  dilatation,  therapeutic  curettage,  and  cauter- 
ization. 

The  pinhole  os  usually  is  congenital  and  chiefly  confined  to  nul- 
liparae. Figure  94.  It  may,  however,  occur  as  the  result  of  cauteriza- 
tion or  of  too  tight  closure  in  the  operation  for  laceration  of  the  cervix. 
The  constricted  external  os  may  be  opened  by  incision  or  by  forcible 
dilatation.  After  the  application  of  either  of  these  methods  the  os  is 
liable  to  recontract.  Schroeder's  operation,  which  gives  permanent 
results,  is  therefore  preferable. 

15 


CHAPTEE    XVI. 

CHRONIC  ENDOMETRITIS. 

In  studying  endometritis,  one  should  remember  that  the  infected 
endometrium  is  usually  only  a  part  of  an  infected  uterus,  and  that 
this  infection  in  many  cases  is  not  limited  to  the  uterus,  but  in  vari- 
able degree  may  involve  the  uterine  appendages  and  parametria. 

The  layer  of  columnar  ciliated  epithelium,  the  connective  tissue, 
the  blood-  and  lymph-vessels,  and  the  nerves  which  compose  the 
endometrium,  are,  like  the  similar  structures  in  the  cervix,  subject  to 
chronic  infection.  Certain  pathological  changes  result  from  this  in- 
fection, and  are  the  essential  factors  of  chronic  endometritis. 

Etiology  of  Chronic  Endometritis. 

The  predisposing  and  exciting  causes  are  the  same  as  already 
described  for  acute  metritis.  The  most  usual  source  of  the  infection 
is  from  the  cervical  mucosa.  There  is  an  untold  amount  of  infection 
carried  to  the  endometrium  by  useless  and  meddlesome  intra-uterine 
treatment. 

Pathology  of  Chronic  Endometritis. 

It  is  here  important  to  remember  that  not  every  increased  secre- 
tion is  proof  of  endometritis.  There  may  be  an  effort  on  the  part  of 
the  mucosa  to  relieve,  by  an  increased  secretion,  a  chronic  venous  con- 
gestion in  and  about  the  uterus ;  or  the  mucous  membrane  of  the 
uterus  in  common  with  that  of  other  organs  may  be  engaged  in 
vicarious  elimination  of  effete  matter  which  the  proper  excretory 
organs  have  failed  to  eliminate  ;  such  conditions  strongly  predispose 
to  and  are  present  in  a  proportion  of  cases  of  endometritis,  but  are 
not  in  themselves  endometritis. 

In  studying  endometritis  microscopically  the  beginner  may  be  at  a 
loss  to  account  for  occasional  irregular  appearances  of  tlie  uterine 
glands,  due  to  invagination  of  the  glands.  Figures  95  to  102,  drawn 
after  a  scheme  suggested  by  Amann,  will  explain  these  irregularities. 

The  general  pathology  has  been  forecast  under  Acute  Metritis. 
The  special  pathology  will  be  presented  in  the  description  of  the 
different  histological  and  clinical  forms. 

Classification  of  Chronic  Endometritis. 

The  general  divisions  of  chronic  endometritis  are  : 

1.  Histological. 

2.  Clinical. 

226 


CHRONIC  ENDOMETRITIS. 

Figure  95.  Figure  99. 


227 


Figure  96. 


Figure  100. 


Figure  97. 


Figure  101. 


V-'... 


Figure  98. 


Figure  102. 


•,.r.ife^' 


"  •-'■\--:: 


^^mm^^j. 


Figures  95-102. 

Explanation  of  scheme  of  gland  invagination.  Figures  95  to  98  show  longitudinal  sections 
of  invaginated  uterine  glands;  Figures  99  to  102  show  cross-sections  of  the  same  gland.  The 
glands  shown  in  longitudinal  section  are  crossed  each  by  a  line  showing  the  plane  at  which  the 
cross-sections  are  made.  Figure  95  shows  invaginated  the  fundus  of  a  gland  with  secondary 
eversion.  Figure  98  shows  intraglandular  papillary  invagination  of  a  gland  epithelium  from 
the  side  of  the  gland.  Figure  96  shows  simple  invagination  of  the  fundus  of  a  gland.  Figure 
97  shows  the  inner  and  outer  segments  regular  and  the  middle  segment  invaginated. 


228     INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 


Histological  Forms  of  Chronic  Endometritis. 

The  histological  forms  of  endometritis  are : 

f  Hypertrophic  glandular  endome- 

1.  Glandular  endometritis      ■[  tt    ^     :    ^.       ,      ,  , 

j  Hyperplastic  glandular   endome- 

1^       tritis. 

2.  Interstitial  endometritis. 

3.  Glandular  and  interstitial  endometritis — mixed  form. 

1.  Glandular  Endometritis. — Glandular  endometritis  is  charac- 
terized by  increase  in  the  size  or  in  the  size  and  number  of  the  glands, 


Figure  103. 


Figure  104. 


'J  V 


/i 


ft         i>        ^ 


■^"^K-S 


:,.";"  I/-"  '^' 


O"     ,.«^^    Cv^' 


Figure  103.— Normal  uterine  mucosa  iu  a  wuiiian  twenty-flve  years  old.  Four  main  glands 
are  shown.  The  small  cross-sections  are  branches  of  the  main  gland.  The  glands  dip  down  to 
and  ver>  little  into  the  niuscularis.    40  diameters. 

Figure  104.— Normal  uterine  mucosa  after  the  menopause.  The  size  of  this  drawing  as 
related  to  that  of  Figure  103  shows  the  shrinkage  which  takes  place  at  the  menopause.  The 
uterine  glands  have  been  obliterated  almost  entirely  by  atrophy.  This  condition  somewhat 
resembles  that  of  interstitial  endometritis.    40  diameters. 

and  accordingly  is  subdivided  into  :  a .  Hypertrophic  ;  b.  Hyperplastic. 
a.  Hypertrophic     Crlandular    Endometritis. — The    normal    uterine 


PLATE   IV 


FIGURE   1. 


1^  "^^^ffe^ 


FIGURE  2. 


'^  ^K'ffirt^r^k-'--'-^^  ^ 

,j^  /■*>>  ^                 ^^■^< 

Si-.7rv.. 

|>^ 

^      r     -.T"                                                                        ^ 

^^)v- 

/.'^c-.v 

1^"' 

*'    "-I-  r.  ^"-i^    ~-   "                                        PARKER 

FIGURE  3. 


CHRONIC  ENDOMETRITIS.  229 

glands  are  tubular,  approximately  straight,  branch  but  little,  run 
almost  perpendicular  to  the  surface,  may  extend  to  the  muscularis — 
that  is,  to  the  myometrium ;  and  but  rarely  dip  down  so  far  as  to 
penetrate  even  to  the  superficial  layer  of  it.  In  hypertrophic  endome- 
tritis the  glands  increase  in  size,  become  proportionately  irregular  in 
outline,  pursue  a  direction  less  perpendicular  to  the  surface,  dip  more 
deeply,  develop  numerous  branches,  become  tortuous  ;  and  in  conse- 
quence of  dilatation  in  some  places  and  constriction  in  others,  fre- 
quently take  on  great  irregularity  of  lumen.  There  is  lining  the 
glands  a  single,  and  only  a  single  layer  of  columnar  epithelium,  with 
enlargement  of  the  individual  epithelial  cells.  Such  is  the  picture  of 
chronic  hypertrophic  glandular  endometritis.     (Plate  IV.,  Figure  1.) 

6.  Hyperplastic  Glandular  Endometritis. — This  form  of  endometritis 
not  infrequently  presents  all  the  essentials  of  the  hypertrophic  variety, 
but,  as  a  distinguishing  characteristic,  will  show  increase  in  the  num- 
ber of  glands ;  this  increase  necessarily  takes  place  at  the  expense  of 
the  interglandular  connective  tissue,  so  that  the  interglandular  spaces 
no  longer  maintain  the  normal  ratio  of  four  times  the  diameter  of 
the  glands  ;  but  may,  on  the  contrary,  almost  wholly  give  way  to  the 
encroachments  of  the  newly  formed  glands.  Increase  in  the  number 
of  glands  results  from  a  process  of  budding  of  the  glands  or  of 
invagination  from  the  surface  epithelium.     (Figures  95—102.) 

The  hyperplastic  form  of  endometritis  is  regarded  by  some  pathol- 
ogists as  a  new  growth,  and  sometimes  is  called  benign  adenoma. 
The  consensus  of  opinion,  however,  is  in  favor  of  attributing  to  such 
growths  an  inflammatory  origin,  and  of  placing  them  in  an  inter- 
mediate position  between  inflammatory  growths  and  new  formations. 
In  this  work  the  term  adenoma  will  not  be  used  to  describe  hyper- 
plastic endometritis,  but  will  be  reserved  for  the  malignant  glandular 
growths.     (Plate  IV.,  Figure  2.) 

2.  Interstitial  Endometritis. — Interstitial  endometritis  is  char- 
acterized by  an  increase  in  the  connective  tissue  of  the  endometrium 
at  the  expense  of  the  glandular  elements,  and  is  therefore  the  reverse 

Explanation  or  Plate  IV. 

Figure  1. — Hypertrophic  glandular  endometritis.  The  glands  are  swollen  and 
tortuous,  but  not  increased  in  number.  In  the  upper  left-hand  corner  is  a  triangle  of 
uterine  muscular  tissue  containing  five  glands.  The  dipping  of  these  glands  far  into 
the  muscular  tissue  may  sometimes  raise  tne  suspicion  of  carcinoma.  The  remaining 
glands  are  surrounded  by  a  stroma  of  embryonic  cells — that  is,  the  cells  which  produce 
connective  tissue.  This  iield  contains  seven  blood-vessels,  indicated  by  the  red  color. 
In  the  middle  of  the  left  half  are  four  glands  all  having  tangential  cuttings.  This  is 
mistaken  sometimes  for  proliferation  of  epithelium.  Similar  cuttings  of  two  glands 
appear  in  the  lower  part  of  the  picture  on  the  right  side.  Small  round  cells  of  inflam- 
mation, as  indicated  by  dark  staining,  appear  here  and  there  in  groups  and  sometimes 
widely  scattered.     80  diameters. 

Figure  2. — Hyperplastic  glandular  endometritis  ( hemorrhagic  K  Observe  some  of 
the  glands  invaginated  and  therefore  characteristic  of  hyperplasia.  The  blood-vessels 
and  the  exti-avasated  blood  are  seen  scattered  over  the  field.  Also  much  congestion  is 
seen  near  the  surface  epithelium  at  the  upper  margin.     15  diameters. 

Figure  3. — A  part  of  Figure  2  highly  magnified.  Observe  the  hemorrhagic  and 
congested  areas,  the  full  blood-vessels,  the  swollen,  invaginated,  and  tortuous  glands, 
which  are  increased  in  size  and  number.  A  characteristic  specimen  of  hemorrhagic 
endometritis.     100  diameters. 


230    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

of  the  hyperplastic  glandular  forms.  In  the  normal  endometrium 
the  connective  tissue  is  embryonal  in  type  and  composed  of  spindle 
cells  loosely  associated.  In  interstitial  endometritis  these  cells  increase 
and  mature  into  fibres  which  separate  the  glands  widely.  The  eiFect 
of  these  connective-tissue  changes  is  to  shut  off  the  nutrition  of  the 
glands,  and  thereby  to  crush  out  and  partially  or  completely  to 
destroy  them.  The  outlets  of  the  glands  may  close  and  give  rise  to 
retention  cysts ;  this  is  called  cystic  endomet'itis.  Finally,  the  endo- 
metrium may  become  a  thin  layer  of  contracted  cicatricial  tissue,  not 
unlike  that  produced  by  the  atrophic  changes  of  old  age.     (Plate  V.) 

Figure  105. 


Polypoid  endometritis :  removal  by  curettage. 

3.  Glandular  and  Interstitial  Endometritis. — Glandular  and 
interstitial  endometritis  often  are  combined  in  varying  proportions. 
Part  or  all  of  the  endometrium  may  be  involved. 

Mucous  Polyps  of  the  uterus,  commonly  caWed polypoid  endometritis, 
are  to  be  regarded  as  of  inflammatory  origin,  are  found  both  in  inter- 
stitial and  in  glandular  endometritis,  and  are  apt  to .  be  developed 
where  there  is  a  concurrence  of  interstitial  endometritis  with  great 
glandular  enlargement ;  they  are  marked  by  excessive,  diffuse,  glan- 


PLATE  V 


^j3»*'' 


,am.if^f^^..  J^ 


i- 

M.         ;     J 

■-..-.■'-                -^ 

4"= 

t 

\ 

1   V 

-'' 

'  ■'  '■.-;_ 

_^       ■?  -      ^  1 

tt.»»LS 

- 'r 

'■■-     '     .= 

!^m0^^M 

Interstitial  Endometritis  (Cystic). 

The  free  mucous  surface  is  shown  in  the  upper  margin  of  the  picture.  A  gland 
in  longitudinal  section  penetrates  the  stroma  on  the  left.  Single  layers  of  glandular 
epithelium  in  some  places  have  been  detached  and  destroyed.  In  some  of  the 
glands  the  epithelium  lining  is  intact,  in  others  it  partially  has  been  shed.  The 
large  cystic  gland  in  the  centre  of  the  figure  shows  much  detached  epithelium 
which  at  some  points  still  preserves  its  form  and  in  others  has  become  degen- 
erated. Near  the  centre  of  the  figure  is  an  enormously  large  bloodvessel,  and 
scattered  over  the  field  are  numerous  small  vessels,  all  having  very  thick  walls. 
The  interglandular  stroma  here  is  fibrous  in  character,  and  the  quantity  of  it  is 
much  increased  while  the  glands  are  decreased.     30  diameters. 


CHRONIC  ENDOMETRITIS. 


231 


dular  and  v'ascular  development  and  by  cystic  degeneration  of  the 
glands.  Some  of  the  cystic  glands  have  the  character  described 
under  interstitial  endometritis ;  others  become  fungoid  projections 
upon  the  surface — that  is,  small,  soft,  polypoid  bodies,  like  nasal 
polypi ;  often  pedunculated,  variable  in  size,  and  oedematous  from 
retained  secretions.  These  changes  make  the  endometrium  exces- 
sively thick,  soft,  and  oedematous.  The  excessive  glandular  and 
vascular  enlargement  explains  the  chief  subjective  symptoms — ex- 
haustive glandular  secretions  and  hemorrhage.  These  polypoid  bodies 
are  not  to  be  regarded  as  new  growths,  and  therefore  should  not  be 
classed  as  adenomata. 

Clinical  Forms  of  Chronic  Endometritis. 

The  clinical  varieties  of  endometritis  usually  may  be  referred  to 
one  or  more  of  the  histological  forms.  The  individual  peculiarities 
are  dependent  upon  intercurrent  conditions.  Among  the  clinical 
forms  are  : 

1.  Post-abortum  endometritis. 

2.  Exfoliative  endometritis. 

3.  Senile  endometritis. 

4.  Tubercular  endometritis. 

5.  Decidual  endometritis. 

In  addition  to  tubercular  endometritis  may  be  mentioned  other 
bacterial  forms  such  as  gonorrhoeal,  syphilis,  and  streptococcic.     Here 


Figure  106. 

^^BWeR^^JTS/.  .sZfejaH 

1 

l^^^l 

1 

^1 

Cast  from  uterine  cavity  in  exfoliative  endometritis — membranouB  dysmenorrhcea,  natural  size. 

belong  also  those  forms  of  endometritis  following  the  acute  infectious 
diseases — typhoid  fever,  diphtheria,  scarlet  fever,  smallpox,  etc. 


232    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 


1.  Post-abortum  Endometritis. — Abortion  may  be  a  cause  or  an 
effect  of  endometritis.  The  inflammation,  which  is  rather  interstitial 
than  glandular,  causes  an  arrest  of  involution  in  the  mucous  membrane 
at  the  site  of  the  ovule  and  of  the  adjacent  mucosa — i.  e.,  of  the  decidua 
serotina  and  decidua  vera.  The  arrest  of  involution  in  localized  areas 
may  give  rise  to  islands  of  decidual  cells  circumscribed  within  the 
surrounding  mucous  membrane  by  the  round  cells  of  inflammation. 

2.  Exfoliative  Endometritis,  called  membranous  dysmenorrhoea, 
is  characterized  by  the  detachment  of  a  membranous  structure  from  the 
endometrium  in  fragments  or  as  a  whole,  and  the  expulsion  of  it  from 
the  uterus.  It  may  occur  at  puberty,  with  the  first  menstruation,  and 
continue  indefinitely,  or  may  begin  at  any  time  during  menstrual  life. 
The  character,  quantity,  and  completeness  of  the  thrown-off  mem- 
brane vary  with  individuals,  and  from  time  to  time  in  the  same  indi- 
vidual. 

The  membranes  thrown  off  in  the  form  of  dysmenorrhoea  closely 
resemble  in  gross  appearance  those  of  early  abortion  and  tubal  preg- 
nancy. The  differential  diagnosis  between  these  three  conditions  is 
therefore  important : 


Exfoliative  endometritis. 

1.  No  history  of  pregnancy. 

2.  Dysmenorrhoeic  pain  and 
discharge  of  membrane  at  each 
menstrual  epoch. 

3.  No  enlargement  of  uterus 
or  Fallopian  tube. 

4.  Chorionic  villi  and  am- 
nion absent. 

5.  No  foetus. 

6.  Membrane  may  be  exact 
cast  of  endometrium  or  may 
be  in  shreds. 

7.  Usually  incurable. 


Early  abortum. 

1.  History  of  pregnancy. 

2.  Discharge    of    membrane 
with  pain  at  time  of  abortion. 


3.  Enlargement  of  uterus,  but 
not  of  Fallopian  tube. 

4.  Chorionic  villi  and  am- 
nion present. 

.5.  Foetus  discharged  from 
uterus. 

6.  Membranes  may  envelop 
fcetus  and  may  be  cast  off 
whole  or  may  be  in  fragments 
or  shreds. 

7.  Self-limited,  or  curable  by 
treatment. 


Tubal  pregnancy. 

1.  Atypical  history  of  preg- 
nancy. 

2.  Discharge  of  decidual 
membrane  usually  between  the 
fourth  and  ninth  week  of  preg- 
nancy. 

3.  Enlargement  of  Fallopian 
tube  on  affected  side. 

4.  Absent  from  uterus.  Chor- 
inonic  villi  and  ammion  in 
Fallopian  tube. 

5.  No  fcEtus  discharged  from 
uterus. 

6.  Membrane,  not  associated 
with  fcetus,  cast  off  entire  or 
in  irregular  fibrous  fragments. 

7.  Not  incurable. 


The  pains  of  membranous  dysmenorrhoea  are  like  severe  labor- 
pains  ;  they  usually  appear  before,  and  continue  with  remissions 
throughout,  the  flow.  The  subjective  symptoms  may  disappear  in  the 
intermenstrual  period,  or  they  may  continue  as  the  ordinary  signs  of 
endometritis,  the  inflammation  taking  on  a  somewhat  acute  character 
during  menstruation.  The  disease  is  intractable,  and  often  incurable. 
The  treatment  is  the  same  as  for  obstinate  endometritis  in  general — 
i.  e.,  thorough  sharp  curettage,  with  cauterization  of  the  endometrium, 
in  the  hope  that  the  new  endometrium  may  be  healthy.  Maternity 
sometimes  effects  a  radical  cure.  See  Chapter  LIII.  Some  authors, 
perhaps  with  good  reason,  deny  that  membranous  dysmenorrhoea  is 
caiised  by  inflammation. 

^.  Senile  Endometritis. — After  the  menopause,  when  the  uterus 
has  undergone  senile  atrophy,  it  is  subject  to  a  most  harassing  form  of 
purulent  endometritis  which  is  usually  the  relic  of  an  earlier  infection, 
and  due  to  the  action  of  bacteria  on  the  atrophic,  less  resisting  endo- 
metrium. The  discharge  contains  numerous  bacteria,  is  commonly 
offensive,    purulent,  often  tinged  with  blood,   and  is  so  irritating  as 


PLATE  VI 


FIGURE   1 


S^'.- 


'm^^^ 


.^^ 


FIGURE  2 


FIGURE  3. 


CHRONIC  ENDOMETRITIS.  233 

sometimes  to  cause  a  most  distressing  pruritus  vulvae.  The  infection 
may  destroy  the  exhausted  senile  mucosa  and  penetrate  into  the  mus- 
Gularis.  Cicatricial  stenosis  and  even  complete  cicatricial  occlusion  in 
the  uterine  canal,  usually  at  the  internal  os,  may  occur  causing  the 
uterine  secretions  to  be  retained  and  the  distended  organ  to  become  a 
thin-walled  retention-cyst — pyometra  or  hydrometra,  according  as  the 
retained  fluid  is  purulent  or  watery ;  this  obstruction  to  the  drainage 
of  secretions  aggravates  the  disease,  and  the  organ  may  remain  large 
from  distention.  The  retained  products  of  senile  endometritis  may 
give  rise  to  reflex  disturbances,  innutrition,  and  to  systemic  depression, 
even  to  general  chronic  toxaemia.  In  most  cases  of  senile  endome- 
tritis the  uterus  is  not  enlarged,  but  rather  in  a  state  of  full  senile 
atrophy. 

The  microscopical  changes  are  like  those  of  atrophic  interstitial 
endometritis,  already  described.  The  glands  and  epithelial  elements 
in  the  last  stages  of  the  disease  are  destroyed  and  the  submucous 
structures  laid  bare,  making  catarrhal  inflammation  impossible.  The 
exposure  of  fibrous  tissue,  on  the  other  hand,  is  favorable  to  the 
development  of  suppuration,  granulation,  and  ulceration — three  charac- 
teristics of  senile  endometritis.  The  disease  may  be  corporeal  or 
cervical,  or  both.  The  ofi'ensive  discharge,  the  occasional  uterine 
enlargement,  and  systemic  depression  may  lead  to  confusion  between 
this  disease  and  uterine  cancer.  Cicatrization  may  bring  about  a 
spontaneous  cure.  Usually,  however,  unless  cut  short  by  treatment, 
the  su])puration  persists. 

4.  Tubercular  Endometritis. — Tubercular  endometritis  may  reach 
the  uterus  from  without  (hetero-infection)  or  may  be  transmitted  from 
another  infected  organ  (auto-infection).  See  Tubercular  Salpingitis, 
Hetero-infection  is  rare,  but  may  be  transmitted  to  the  cervix  uteri  or 
vagina  by  coitus  or  by  instrumental  or  digital  interference,  and  may 
take  the  form  of  sharply  cut  ulcers,  and  when  far  advanced  may 
extend  to  the  corpus  uteri ;  the  resemblance  to  cancer  is  then  quite 
marked.  Auto-infection  generally  reaches  the  uterus  through  the 
Fallopian  tubes.  In  such  cases  the  disease  finally  extends  from  the 
endometrium  to  the  myometrium,  and  not  uncommonly  to  the  lungs. 

Explanation  of  Plate  YI. 

Figure  1. — Post-aboitum  endometritis.  Section  of  endometrium  removed^  by  the 
curette  after  abortion.  The  upper  left-hand  corner  contains  decidual  cells  with  two 
small  blood-vessels.  The  remainder  of  the  field  is  occupied  by  chorionic  villi.  In 
most  of  the  villi  blood  vessels  either  in  longitudinal  or  cross-section  are  sho\vn.  The 
villi  are  surrounded  by  two  layers  of  cells,  the  inside  layer  being  the  ectodermal  epi- 
thelial layer  of  Langhans,  the  outer  layer  being  the  uterine  epithelial  layer  of  the 
chorion — that  is,  the  syncytium.     80  diameters. 

Figure  2.— Menstrual  decidua  from  membranous  dysmenorrhoea  as  seen  by  the 
microscope.  The  upper  border  is  composed  of  surface  columnar  epithelium  sorne- 
what  flattened.  There  are  three  glands  lined  with  columnar  epithelium.  The  remain- 
der of  the  field  is  made  up  of  decidual  cells  among  which  are  scattered,  especially  in 
the  centre  of  the  field,  numerous  small  round  cells  of  inflammation.     80  diametei-s. 

Figure  3. — Uterine  decidua  commonly  cast  off  in  tubal  pregnancy  at  the  time  of 
spurious  labor.  The  outer  margins  and  open  spaces  are  torn  and  ragged.  The  draw- 
ing shows  three  blood-vessels  full  of  blood.  The  decidual  cells  are  large  and  irregular 
with  small  nuclei.  The  decidua  of  tubal  pregnancy  seldom  shows  glands  and  none  are 
seen  here.     80  diameters. 


234    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

There  is  also  usually  a  prior  involvement  of  the  peritoneum.  Often  the 
pelvic  organs — uterus,  bladder,  colon,  rectum,  ovaries,  and  tubes — are 
matted  together  by  adhesions,  with  abscesses  and  broken-down  tissues. 
Tubercular  endometritis  is  relatively  rare ;  it  is  recognized  by  the 
history  of  the  case  and  by  microscopical  examination  of  the  scraping. 
The  disease  is  incurable  by  any  means  except  hysterectomy. 

5.  Decidual  Endometritis  arises  during  pregnancy.  A  positive 
diagnosis  cannot  be  made  until  pregnancy  has  terminated  and  the 
decidual  changes  have  been  noted  under  the  microscope.  The  symp- 
toms suggestive  of  the  condition  are  hemorrhage,  leucorrhoea,  and 
pain,  all  of  which  may  continue  throughout  pregnancy.  The  pain  is 
referable  to  the  uterus,  and  may  be  of  the  cramping  and  bearing-down 
variety.  Early  abortion  with  a  firmly  adherent  placenta  is  the  usual 
result. 

Symptoms  of  Chronic  Endometritis. 

The  symptoms  of  acute  endometritis — that  is,  hypogastric  pain, 
pelvic  weight,  rectal  and  vesical  tenesmus — may  in  some  degree  con- 
tinue ;  but  as  the  disease  becomes  chronic  these  symptoms  cease  to 
predominate ;  in  their  place  comes  a  symptom-group  which  always 
contains  some  of  the  following  factors : 

Menstrual  and  intermenstrual  disturbances. 

Excessive  mucous,  purulent^  or  mucopurlent  discharges. 

Uterine  hemorrhages. 

Sterility  or  frequent  abortions. 

Dragging  sensation  in  pelvis. 

Pain  in  epigastrium. 

Vesical  and  rectal  tenesmus,  frequent  urination. 

Systemic  disturbances  and  reflex  disorders  in  other  organs,  such  as 
flashes  of  heat  and  cold,  insomnia,  troubled  dreams,  and  sometimes  a 
radical  change  in  disposition. 

The  above  symptoms  often  are  observed  in  other  disorders,  and  are 
therefore  not  strongly  diagnostic. 

Fain. — Obstructive  dysmenorrhcea  may  result  from  cicatricial 
stenosis,  especially  if  the  menstrual  blood  coagulates  in  the  uterus 
and  is  forced  out  by  strong  contractions ;  the  pain  will  then  be  inter- 
mittent. Intermenstrual  pain  from  the  expulsion  of  accumulated 
secretion  in  the  uterus  may  occur  in  the  same  way.  The  excessive 
menstrual  pain,  like  labor-pain,  in  exfoliative  endometritis  has  already 
been  mentioned.  Congestive  dysmenorrhcea  often  precedes  the  flow, 
but  subsides  as  soon  as  the  engorged  vessels  are  relieved  by  the  estab- 
lishment of  the  flow.  The  uterine  nerves,  already  sensitive  from 
neuritis  when  crowded  by  the  distended  blood-vessels  of  the  swollen 
uterus,  easily  become  the  seat  of  great  menstrual  and  intermenstrual 
pain. 

Hypersecretion  is  a  constant  and  pronounced  symptom.  It  may  be 
catarrhal  or  purulent,  or  mixed,  and  often  contains  blood.  Menor- 
rhagia and  intermenstrual  hemorrhage  are  common. 

Sterility  and  Abortion  are  associated  frequently  with  the  disease. 
Sterility  may  result  from  complicating  ovaritis  or  obstruction  in  the 


CHRONIC  ENDOMETRITIS. 


235 


Fallopian  tubes,  or  from  destruction  of  the  spermatozoa  by  the  uterine 
secretions,  or  from  their  mechanical  exclusion  from  the  uterus  by  the 
plug  of  tenacious  mucus  usually  found  in  endocervicitis ;  or  from  the 
hostile  influence  of  the  diseased  uterine  mucosa  on  the  ovule.  The 
failure  of  the  ovule  to  implant  itself  upon  the  mucosa  may  give  rise 
to  no  subjective  symptoms,  and  the  fact  of  early  abortion  may  be 
unrecognized.  Indeed  unrecognized  early  abortions  may  occur  at 
frequent  intervals  and  for  a  long  period  of  time. 


Figure  107. 


Figure  108. 


URE  107.— Hyperplastic  glandular  endometritis.    The  glands  are  increased  in  size  and 

r,  greatly  tortuous,  and  dip  decidedly  into  the  muscularis.    The  interglandular  spaces 

■    "  '      This  condition  sometimes  is  called  benign  adenoma.  Semidiagrammatic. 


FlGURli 

number,  _ 

are  much  decreased. 

Figure  lOS.— Same  as  Figure  107.  Modified  in  the  lower  part  by  carcinoma,  commonly 
called  adenocarcinoma.  There  is  great  rarefaction  of  stroma  and  in  the  carcinomatous  part 
the  glands  are  so  tortuous  and  atypical  that  they  cannot  be  traced.  Carcinoma  is  demon- 
strated here  by  the  breaking  through  the  tunica  propria  into  the  stroma  and  the  invasion  of 
the  stroma  by  proliferated  gland  epithelium  which  also  fills  the  glands.  The  lower  left-hand 
corner  shows  a  gland  which  shows  much  cell  proliferation,  and  which  may  be  regarded  as  the 
earliest  stage  of  cancer  formation,  but  not  a  condition  upon  which  a  positive  diagnosis  should 
be  made.    Semi-diagrammatic. 


The  Systemic  and  Reflex  Disorders  are  chiefly  referable  to  the 
nervous  svstein.  Among  them  are  neuralgia,  indigestion,  malnutri- 
tion, nervous  dyspepsia,  anaemia,  chlorosis,  spinal  irritation,  and 
hysteria.  The  endometritis  may  be  a  cause  or  an  effect  of  the  above 
associated  disorders,  or  together  with  them  may  be  a  concurrent  result 
of  some  common  cause,  or  may  have  primarily  no  pathological  con- 
nection with  them.  The  nervous  symptoms  are  usually  most  pro- 
nounced during  the  few  days  before  menstruation,  and  may  be  very 
marked  during  the  flow. 


236    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Diagnosis  of  Chronic  Endometritis. 

The  diagnosis  of  chronic  endometritis,  suggested  by  the  symptomb 
outlined  above,  must  depend  upon  curettage  and  a  microscopical 
examination  of  the  scrapings.  Digital  examination  will  in  many 
cases  show  increased  size  and  hardness  of  the  uterus,  and  is  espe- 
cially essential  as  a  means  for  the  detection  of  complications,  such  as 
displacement  and  ciroumuterine  inflammations.  A  very  small  curette, 
without  previous  dilatation,  will  suffice  often  for  diagnostic  purposes  ; 
at  least  it  may  settle  the  question  whether  a  therapeutic  curettage  is 
necessary. 

A  discharge  from  the  vagina  or  from  the  Fallopian  tubes  may  be 
mistaken  for  the  product  of  endometritis.  Inspection  will  show 
whether  the  discharge  comes  from  the  uterus  or  not.  The  tube  may 
refill  and  empty  itself  through  the  uterus  at  intervals,  giving  rise  to 
periodical  expulsive  pains  in  the  uterus — colica  scrotorum. 

Pus  from  a  pelvic  abscess  is  recognized  by  finding  the  sinus 
through  which  it  discharges ;  such  a  sinus  often  opens  into  the 
vagina  near  the  uterus,  seldom  into  the  uterus. 

Differential  Diagnosis  of  Chronic  Endometritis. 

The  diagnosis  between  the  different  forms  of  endometritis  and 
between  endometritis  and  malignant  disease  will  depend,  first,  upon 
the  history  of  the  case,  the  nature  of  the  discharge,  and  conjoined 
examination  ;  second,  upon  the  findings  of  the  curette  and  the  micro- 
scope. The  discharges  from  carcinoma  and  sarcoma,  unlike  those  of 
endometritis,  are  more  profuse,  more  offensive,  more  watery,  and 
usually  contain  more  blood.  Cachexia  and  other  systemic  disorders 
are  quite  marked  in  sarcoma  and  carcinoma,  but  usually  absent  or 
slight  in  endometritis. 

Figures  107  and  108  show  in  a  diagrammatic  way  the  transition 
from  hyperplastic  endometritis  to  andenocarcinoma. 

The  differential  points  between  the  two  forms  of  chronic  glandular 
endometritis  and  carcinoma  are  shown  in  the  illustrations  on  endome- 
tritis and  carcinoma  and  in  the  following  parallel  columns  : 


Glandular  hypertrophic 
endometritis. 

1.  Glands  increased  in  size 
tut  not  in  number. 

2.  No  proliferation  of  gland 
epithelium. 

3.  Gland  structures  nearly  or 
quite  typical  in  outline. 


4.  Hypertrophied  epithelium 
confined  within  the  limits  of 
the  tunica  propria. 


.5.  Gland-tissue  does  not  in- 
vade muscularis  deeply. 


Glandular  hyperplastic 
endometritis. 

1.  Glands  increased  in   size 
and  number. 


of     gland 


2.  Proliferation 
epithelium. 


3.  Gland  structures  more  tor- 
tuous in  outline. 


4.  Proliferation  confined 
within  the  limits  of  the  tunica 
propria. 


Adenocarcinoma 


1.  Glands  very  greatly  in- 
creased in  size  and  number. 

2.  Very  great  proliferation 
of  gland  epithelium. 

3.  Gland  structures  very 
atypical  in  outline.  See  Fig- 
ure 150. 

4.  The  proliferating  gland 
epithelium  hasbrokenthrough 
the  tunica  propria  and  is  in 
direct  contact  with  intergland- 
ular  connective  tissue,  and  is 
multiplying  in  an  atypical 
manner. 

5.  Gland-tissue  does  not  in-       5.  Gland-tissue     may     very 
vade  muscularis  very  deeply,      deeply  invade  muscularis. 


CHRONIC  ENDOMETRITIS. 


237 


Glandular  hypertrophic 
endomelritis. 

6.  Can  trace  tortuous  glands. 


7.  Stroma  normal  in   quan- 
tity. 


8.  Glands  evenly  distributed. 


Glandular  hyperplastic 
endometritis 

6.  Can  trace  tortuous  glands. 


7.  Stroma  decreased  in  quan- 
tity, but  clearly  defined  from 
glands.  Simple  filling  of  gland 
lumen  with  epithelium  does 
not  necessarily  denote  malig- 
nancy so  long  as  epithelium 
is  confined  within  basement 
membrane,  i.  e.,  within  tunica 
propria. 

8.  Glands  evenly  distributed. 


A  denocarcinoma. 


6.  Glandular  labyrinth  ;  can- 
not trace  tortuous  and  atypical 
gland. 

7.  Great  rarefaction  of  stro- 
ma, so  that  glands  touch  one 
another,  (jlands  have  broken 
through  basement  membrane 
and  invaded  interglandular 
spaces  and  muscularis.  See 
Chapter  XXVIII. 


8.  Gland  elements    may  be 
distributed  very  unevenly. 


The  distinction  between  endometritis  and  sarcoma  is  difficult,  and 
in  early  sarcoma  sometimes  impossible.  The  following  points  are 
significant : 


Endometritis. 

1.  Progress  not  rapid  after  the  acute  stage. 

2.  Cells  do  not  vary  in  size  or  shape. 

3.  Walls    of  blood-vessels    clearly    separate 
cells  from  blood-supply. 


4.  Endometritis  first  involves  superficial 
structure,  and  later  may  involve  deeper 
structure. 


Sarcoma. 

1.  Progress  very  rapid,  especially  in  the 
small  round-cell  variety. 

2.  Vary  most  widely. 

3.  Intimate  relation  of  blood-spaces  to  cells. 
Walls  of  vessels  may  be  absent,  leaving  only 
blood-spaces. 

4.  Sarcoma  often  involves  deeper  layer  first. 


Prognosis  of  Chronic  Endometritis. 

Relapse  is  very  common.  The  mildly  infectious  cases,  usually 
called  simple  endometritis,  are  self-limited  or  yield  readily  to  systemic 
treatment,  l^he  strongly  infectious  cases  always  require  surgical  treat- 
ment. This  in  most  cases  will  bring  about  at  least  a  symptomatic 
cure — i.  e.,  it  will  stop  the  discharge  and  may  relieve  other  symptoms. 
Whether  the  diseased  uterine  mucosa  can  be  restored  to  its  functions 
will  depend  upon  the  extent  to  which  it  has  been  impaired  by  the 
disease  or  must  be  destroyed  by  treatment.  The  prognosis  is  especi- 
ally discouraging  in  interstitial  exfoliative,  senile,  and  tubercular 
endometritis. 


CHAPTER    XVII. 
CHRONIC  ENDOMETRITIS  (Continued). 

Treatment  of  Chronic  Endometritis. 

The  treatment  varies  with  the  structures  involved,  the  nature  of 
the  infection,  the  chronicity  of  the  disease,  and  with  the  preponder- 
ance of  systemic  or  local  origin.  The  treatment  of  cervical  differs 
from  that  of  corporeal  endometritis ;  that  of  a  gonococcus  infection 
might  have  to  be  energetic  and  strong,  while  a  milder  infection  would 
require  only  simple  or  expectant  treatment.  Obstinate  cases  of  long 
standing  may  yield  only  to  the  most  radical  surgical  measures.  Many 
authors  attempt  to  draw  a  line  between  what  they  call  simple  endo- 
metritis and  bacterial  endometritis.  This  line  can  have  neither  a 
scientific  nor  a  clinical  basis.  It  is  better  to  distinguish,  on  the  one 
hand,  tlie  non-purulent  cases  of  uterine  catarrh  in  which  general  circu- 
latory disturbances  predominate  ;  and,  on  the  other  hand,  the  cases  in 
which  infection  j^redominates  :  in  the  first  class  of  cases  predisposing 
causes  predominate ;  in  the  second  class,  exciting  causes.  See  Chap- 
ter X.  The  septic  element  is  not  confined  to  the  second  class,  nor  the 
systemic  element  to  the  first.  An  appreciation  of  the  foregoing  will 
suggest  the  following  division  of  treatment : 

1.  Systemic  treatment. 

2.  Topical  treatment. 

3.  Surgical  treatment. 

1.  Systemic  Treatment  of  Chronic  Endometritis. — Should 
Treatment  be  Systemic  or  Local  ? — Systemic  treatment  is  applicable 
to  a  very  large  class  of  cases,  sometimes  called  subinflammatory,  Avhich 
arise  not  so  much  from  local  infection  as  from  stagnation  of  the  gen- 
eral circulation.  The  stagnation  is  associated  not  infrequently  with 
disorders  of  the  heart,  lungs,  liver,  kidneys,  or  with  such  disorders  as 
anaemia,  rheumatism,  and  gout.  The  uterus  may  participate  in  the 
general  circulatory  disturbance  and  take  on  a  catarrhal  condition.  In 
this  class  of  cases  the  catarrh  usually  involves  not  only  the  uterus,  but 
also  extrapelvic  organs,  especially  the  organs  of  the  respiratory,  diges- 
tive, and  urinary  systems.  The  raucous  membranes  generally  become 
less  resistant  and  therefore  more  liable  to  infection.  Catarrh  is  often 
the  vicarious  act  of  a  mucous  membrane  to  throw  off  waste-products 
which  it  would  not  normally  have  to  eliminate  at  all.  When  the 
membrane  is  relieved  of  such  unnatural  function  the  resistance  to  the 
microbe  is  increased,  and  in  this  way  the  discharge  may  cease. 

It  is  clear  from  the  foregoing  that  in  the  absence  of  marked  local 
infection  the  treatment  should  be  not  so  much  local  as  systemic,  and 

238 


CHRONIC  ENDOMETRITIS.  239 

that  when  the  uterine  discharge  is  mainly  consequent  upon  systemic 
causes,  local  treatment  may  be  useless,  perhaps  injurious.  On  the  other 
hand,  the  uterus  may  participate  in  the  general  improvement  when  the 
extrapelvic  and  systemic  disorders  mentioned  in  the  preceding  para- 
graph have  been  relieved.  If  the  uterine  secretions  are  purulent,  or 
if  systemic  treatment  proves  inadequate,  topical  or  surgical  treatment 
may  be  desirable. 

The  Kidneys  should  be  made  to  eliminate  their  pro})er  amount  of 
urea  and  other  solids.  A  quantitative  urinalysis  should  be  made  to 
estimate  the  total  solids  excreted  in  twenty-four  hours  ;  and  if  there  is 
deficient  elimination  the  granular  eflPervescing  sodium  phosphate  in 
copious  draughts  of  pure  soft  water  or  mineral  spring  waters  are 
indicated ;  the  diet  should  include  less  animal  and  more  vegetable 
food. 

Anaemia,  notably  the  anaemia  of  fat  flabby  women,  often  is  associated 
with  local  engorgement,  especially  in  the  uterus.  In  such  cases  local 
treatment  is  useless.  Iron,  manganese,  the  bitter  tonics,  mineral 
waters,  nutritious  food,  adequate  exercise,  and  regular  habits  are 
essential.  The  thyroid  extract  has  been  much  praised  in  the  treat- 
ment of  this  class  of  anaemic  women,  and  the  use  of  it  is  said  to  be 
followed  by  reduction  of  fat. 

Constipation  is  associated  almost  constantly  with  uterine  catarrh. 
Large  accumulations  of  old,  hard  fecal  matter  displace  and  keep  up 
constant  engorgement  of  the  uterus  and  other  pelvic  organs.  The 
successful  treatment  of  constipation  is  sometimes  essential  in  the 
treatment  of  the  endometritis  and  should  be  rather  regulative  than 
medicinal.  Strong  laxatives  tend  to  congest  the  abdominal  and  pelvic 
organs — the  very  condition  we  want  to  relieve — and  should  therefore 
be  avoided.  Hygienic  measures  alone  may  be  adequate.  These 
include  regular  ])roperly  selected  diet,  regularity  in  exercise  and  espe- 
cially in  times  of  going  to  stool.  Massage  is  a  measure  valuable  for  its 
direct  influence  on  the  action  of  the  bowels  and  on  the  general  circu- 
lation. Mineral  waters,  magnesium  sulphate,  magnesium  citrate, 
lithium  citrate,  sodium  phosphate,  and  Carlsbad  salt  are  useful,  and 
are  given  best  in  copious  draughts  upon  rising  in  the  morning.  A 
large  draught  of  cold  water  at  the  same  hour  will  often  cause  free 
action  of  the  bowels.  The  more  positive  cathartics  like  aloin  or  podo- 
phyllin  at  bedtime,  which  usually  act  strongly  the  next  morning,  are 
objectionable,  and  such  drugs  if  given  at  all  should  be  in  small 
divided  doses  combined  with  iron  and  nux  vomica,  and  given  at  least 
three  times  a  day.  The  cathartic  dose  should  be  diminished  each  time 
the  prescription  is  renewed  until  only  the  tonic  remains.  Polyj)har- 
macy  is  to  be  avoided. 

Tablet  triturates  of  calomel  long  continued  in  small  doses — one- 
thirtieth  to  one-tenth  of  a  grain — three  times  a  day  may  fulfil  clear 
indications  ;  it  stimulates  the  biliary  secretion,  renders  the  glandular 
organs  more  active,  dislodges  morbid  accumulations,  and  tends  to 
secure  proper  elimination  through  the  bowels  and  kidneys.  The  bi- 
chloride of  mercury  in  minute  doses — one-hundredth  of  a  grain — 
may  be  equally  useful.     In  the  continued  employment  of  mercurials 


240    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

it  is  Avell  to  secure  normal  freedom  of  the  bowels,  if  necessary,  by  the 
judicious  use  of  salines. 

Colonic  flushings  of  normal  salt  solution  are  most  useful,  espe- 
cially in  the  treatment  of  obstinate  constipation.  They  should  be 
given  in  the  left  lateroprone  position  of  Sims.  To  be  most  eflFective 
they  must  be  copious,  slowly  given,  and  retained  for  at  least  several 
minutes.  The  disease  is  most  obstinate  in  virgins.  In  corpulent 
young  women  cure  is  almost  impossible  unless  the  nutrition  be  im- 
proved and  the  weight  reduced. 

General  Hygiene. — Dress,  exercise,  food,  sexual  relations,  care  at 
menstruation,  local  and  general  bathing  are  very  important.  A  com- 
prehensive grasp  of  the  subject  involves  the  whole  field  of  general 
medicine. 

2.  Topical  Treatment  of  Chronic  Endometritis. — Topical  treat- 
ment has  been  as  much  overestimated  as  systemic  treatment  has  been 
neglected.  Multitudes  of  women  have,  unfortunately,  formed  the 
habit  of  receiving  useless  routine  treatment  for  the  relief  of  uterine 
discharges.  Once  eliminate  the  cases  described  in  the  foregoing  para- 
graphs which  require  not  so  much  local  as  systemic  treatment,  and  the 
relatively  small  remainder  will  be  made  up  mostly  of  clearly  infec- 
tious cases.  Few  scientific  gynecologists  to-day  place  great  value  on 
topical  office-treatment  for  clearly  purulent  endometritis.  The 
number  of  such  cases  definitely  cured  by  topical  applications,  when 
compared  with  the  great  number  treated,  is  insignificant.  In  mak- 
ing such  comparison  we  must  exclude  those  w^hich  needed  only 
systemic  treatment,  and  have  been  relieved  by  it,  notwithstanding 
the  associated  topical  treatment  which  they  did  not  need. 

The  endometrium  has  been  the  subject  of  a  vast  amount  of  some- 
times mild,  many  times  useless  or  destructive  topical  treatment. 
Other  organs,  the  nose,  stomach,  intestine,  bladder,  and  eye,  are 
subject  to  the  same  catarrhal  conditions  from  the  same  general  causes. 
Consistency  therefore  might  indicate  topical  treatment  for  them  also. 
If  in  a  given  case,  for  example,  the  whole  intestinal  canal  and  bladder 
and  endometrium  were  catarrhal,  it  might  be  quite  as  reasonable  to 
apply  fuming  nitric  acid  to  all  as  to  one.  Such  an  experiment  would 
not  only  show  that  the  human  uterus  has  endured  an  immense  amount 
of  abuse,  but  would  demonstrate  successfully  the  absurdity  of  topical 
treatment  applied  to  a  mucous  membrane  when  the  discharge  is  only 
one  of  many  local  evidences  of  a  general  condition.  Very  significant 
is  the  fact  that  often-repeated  handling  of  the  genitals  may  give  rise 
to  psychic  irritation  or  depression.  A  woman  once  habituated  to  local 
treatment  may  become  a  monomaniac  on  that  subject. 

Intra-uterine  treatment  as  ordinarily  practised  is  tedious,  and 
whether  mild  or  severe,  if  frequently  repeated  with  indifferent  aseptic 
care,  may  set  up  new  infection,  or  may  carry  the  old  infection  to 
deeper  structures.  Many  cases  which  do  well  on  mild  topical  treat- 
ment would  do  better  on  systemic  treatment  alone. 

Strong  intra-uterine  applications  which  have  the  power  to  destroy 
the  diseased  structures  sometimes  will  arrest  purulent  endometritis, 
but   in   doing  this  they  may  destroy  the  endometrium,    injure   the 


CHRONIC  ENDOMETRITIS.  24l 

myometrium,  and  reduce  the  uterus  to  a  eirrhotic-like,  cicatricial  con- 
dition. Numerous  plastic  operations  have  been  devised  with  but  little 
success  to  reopen  the  contracted  uterine  canals.  The  chloride  of  zinc 
pencil  produces  a  slough  of  the  endometrium  and  sometimes  of  the 
myometrium ;  the  use  of  it  having  destroyed  the  natural  secreting 
surface  may  be  followed  not  only  by  a  chronic  purulent  discharge,  but 
also  by  infection  of  the  appendages  by  extension  from  the  septic 
sloughing  endometrium.  The  endometrium  now  has  lost  permanently 
its  epithelial  covering,  the  chief  protection  of  the  uterus  against 
microbic  invasion.  Contrast  this  condition  with  that  in  which  the 
diseased  structures  have  been  removed  by  an  aseptic  curettage  so  that 
the  healthy  abraded  surfaces  are  all  ready  to  reproduce  a  new  endo- 
metrium, and  the  objection  to  strong  caustics  in  the  endometrium  will 
become  apparent. 

Electricity  is  painful,  tedious,  dangerous,  and  often  unduly  destruc- 
tive. Great  cicatricial  formations  and  hopeless  stenosis  in  the  endo- 
metrium are  among  the  possible  results.  These  effects  are  not  limited 
to  the  diseased,  but  may  include  healthy  structures.  The  immediate 
dangers  are  greater  than  those  of  aseptic  curettage.  Generally  speak- 
ing, the  method  is  not  to  be  approved. 

The  author  has  tested  carefully  the  routine  use  of  topical  applica- 
tions, the  vaginal  douche,  the  swabbing  out  of  the  uterus  with  cotton, 
the  injection  of  astringents,  the  vaginal  and  intra-uterine  application 
of  dry  powders,  intra-uterine  pencils  of  various  alterative  and  caustic 
substances,  wool-glycerin  tamponade,  electricity,  and  intra-uterine 
gauze  tamponade,  and  the  patient  use  of  such  means  has  been  followed 
by  a  few  cures,  and  by  much  disappointment,  to  say  nothing  of  some 
positive  harm.  Topical  treatment  should  not  be  continued  beyond  a 
few  weeks  unless  good  results  have  become  apparent.  It  has  a  more 
legitimate  place  as  a  supplement  than  as  a  substitute  for  systemic  and 
operative  treatment.  A  reproach  will  be  lifted  from  the  medical  pro- 
fession when  the  indiscriminate  use  of  topical  treatment  has  been 
relegated  to  the  dark  ages  of  gynecology. 

If  topical  treatment  is  to  be  used,  especially  if  it  is  to  be  intra- 
uterine— see  Chapters  II.  and  IV. — the  cervix  should  be  exposed 
with  Sims'  speculum,  the  vagina  cleansed  thoroughly  with  dry  absorbent 
cotton  on  dressing-forceps  and  swabbed  with  cotton  saturated  with  a 
5  per  cent,  solution  of  carbolic  acid  or  a  1  per  cent,  solution  of  creolin. 
Slight  traction  is  now  made  on  the  cervix  by  tenacula  or  blunt-tooth 
forceps,  to  straighten  the  uterine  canal,  and  the  endometrium  is 
cleansed  by  means  of  cotton  wound  on  an  applicator.  The  cervical 
plug  of  mucus,  if  present,  should  be  removed.  The  desired  applica- 
tion may  then  be  carried  into  the  endometrium  by  means  of  the 
applicator  wound  with  fresh  absorbent  cotton,  or,  if  the  canal  be  very 
open,  by  means  of  fine  dressing-forceps.  A  pledget  of  cotton  satu- 
rated with  glycerin  or  a  10  per  cent,  mixture  of  ammoniated  iclithyol 
and  glycerin  may  be  placed  in  the  vagina  as  a  protective  and  for  its 
hygroscopic  aifect.  Over  this  place  a  pledget  of  dry  cotton,  to  keep 
the  first  in  position  and  to  absorb  moisture.  The  vaginal  tampon 
should  be  removed  in  twenty-four  hours.     Intra-uterine  cleanliness  is 

16 


242    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

the  first  requisite.     To  secure  this,  an  open  canal  and  normal  drainage 
are  essential.     During  such  treatment  coitus  is  prohibited. 

Intra-uterine  gauze  tamponade  has  been  used  extensively  for  dilata- 
tion and  drainage  in  the  non-operative  cases.  Increasing  quantities  of 
a  narrow  strip  of  antiseptic  gauze  are  packed  into  the  uterus  in  suc- 
cessive treatments,  until  the  endometrium  has  become  gradually  dilated 
to  a  diameter  of  one-third  or  one-half  inch.  This  dilatation  permits 
easy  and  thorough  intra-uterine  topical  treatment  and  drainage,  espe- 
cially capillary  drainage  when  the  gauze  is  in  place.     This  method,  in 


Figure  109. 


Patient  in  dorsal  position.  Cervix  exposed  by  perineal  retractor  in  right  hand  of  nurse. 
Uterus  drawn  down  with  tenaculum  in  left  hand  of  operator.  Any  desired  fluid  may  be  injected 
Into  endometrium  by  means  of  special  canula  attached  to  syringe.  This  syringe,  worked  by 
right  hand  of  operator,  is  shown  in  the  upper  left-hand  corner. "  Canula  here  is  shown  as  detached 
from  the  syringe.  Outflow  of  injected  fluid  is  secured  by  a  wire  attachment  running  parallel 
to  the  canula  and  a  little  below  it.  Sims'  speculum  and  the  left  lateroprone  position  would  be 
preferable  to  the  Simon  speculum  and  the  dorsal  position. 

the  author's  hands,  has  been  successful  occasionally,  but  less  so  than 
the  reports  of  its  advocates  would  seem  to  promise.  Great  care  is 
necessary  lest  the  gauze,  instead  of  carrying  out  septic  material,  may 
carry  it  in. 

It  would  be  confusing,  and  it  is  unnecessary  to  name  the  innumerable 
drugs  and  chemicals  which  are  lauded  for  intra-uterine  medication. 
Carbolic  acid  and  iodine,  for  their  disinfectant  and  astringent  effect, 
meet  the  requirements  in  glandular  endometritis  and  ichthyol  in  inter- 
stitial endometritis  so  far  as  topical  treatment  can  meet  them. 

In  cases  of  purulent  endometritis,  one  may  make  advantageously 


CHRONIC  ENDOMETRITIIS.  243 

a  single  application  of  40  percent,  formalin  to  the  endometrium,  and 
in  some  very  intractable  cases  may  repeat  this  once  or  twice  at  inter- 
vals of  a  month.  This  application  is  made  best  by  means  of  a  uterine 
applicator  wound  with  cotton,  the  vagina  being  protected  by  a  wad  of 
cotton  placed  behind  the  cervix  uteri. 

More  conservative  and  perhaps  more  effective  than  formalin  is  the 
intra-uterine  injection  of  tincture  of  iodine.  Preparatory  to  the  injec- 
tion the  endometrium  should  be  cleasned  thoroughly  either  by  wiping 
out  with  cotton  or  by  irrigation  with  water.  One  drachm  should  be 
injected  at  each  treatment.  In  order  to  prevent  the  tincture  from 
being  forced  through  the  Fallopian  tubes,  it  should  be  thrown  in 
gently  and  allowed  to  run  out ;  the  injection  may  be  repeated  twice  a 
week  ;  if  in  two  months  there  is  not  marked  improvement,  the  treat- 
ment should  be  interrupted  and  if  necessary  resumed  after  curettage. 
The  technique  of  injecting  the  uterus  is  shown  in  Figure  109.  In 
place  of  the  instruments  here  presented  an  ordinary  small  glass 
female  catheter  attached  to  a  common  ear  syringe  by  means  of  a  short 
rubber  tube  may  be  used. 

The  Biers  cupping  congestive  treatment,  described  at  the  end  of 
Chapter  IV.,  is  important  in  connection  with  cleansing  the  endome- 
trium, both  as  an  independent  remedial  measure  and  as  a  preparation 
for  intrauterine  treatment. 

3.  Surgical  Treatment  of  Chronic  Endometritis. 

Indications  for  Curettage. — When  the  endometritis  is  distinctly 
infectious  and  chronic,  both  topical  and  systemic  treatment  are  usually 
inadequate,  although  either  properly  may  supplement  surgical  meas- 
ures. The  disease  of  the  mucosa  should  then  be  removed  by  the 
sharp  curette.  The  operation  is  rendered  extra-hazardous  by  active 
inflammation  in  the  Fallopian  tubes  or  by  any  other  active  pelvic 
inflammation  which  renders  the  uterus  immobile  or  very  sensitive  to 
the  touch.  If  for  any  reason  it  must  be  done  under  these  adverse 
conditions,  the  greatest  aseptic  care  should  be  taken  to  prevent  dan- 
gerous lymphangitis,  phlebitis,  and  peritonitis.  A  general  description 
of  curettage  will  be  found  in  Chapter  V.  Formerly  salpingitis, 
ovaritis,  peritonitis,  and  cellulitis  were  considered  positive  contraindi- 
cations for  invading  the  uterine  cavity.  At  present,  although,  these  dis- 
eases, if  chronic,  call  for  especial  care,  they  are  not  to  be  considered  as 
necessarily  prohibiting  intra-uterine  operations,  provided  these  opera- 
tions are  of  such  a  character  as  to  remove  the  disease  from  the  endo- 
metrium. They  do,  however,  prohibit  all  intra-uterine  interference 
which  falls  short  of  this.  Ordinary  intra-uterine  treatment,  even 
examinations  with  the  sound,  may  be  more  dangerous  than  thorough 
dilatation  and  sharp  curettage.  Incomplete  dull  curettage  is  speciallv 
dangerous,  for  it  exposes  the  surfaces  to  absorption  and  at  the  same 
time  may  leave  infectious  matter  to  be  absorbed.  Inflamed  tubes  and 
ovaries  often  become  healthy,  or  at  least  symptomatically  cured,  after 
the  primary  source  of  infection  has  been  removed  from  the  uterus.  In 
order  to  facilitate  the  curettage  and  insure  drainage  let  the  dilatation 
be  thorough. 


244  INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Technique  of  Curettage. — The  accompanying  series  of  illustrations, 
Figures  110  to  114,  shows  the  steps  of  the  operation  of  sharp 
curettage.  The  dilatation  should  be  begun  with  a  small  light  dilator, 
Figure  110,  and  continued  with  a  larger  dilator  of  the  Wathen  type, 
Figure  111.  This  instrument  is  of  heavy  construction  and  the 
blades  of  it  have  great  expanding  power.  After  the  uterus  has  been 
dilated  to  the  extent  of  one-half  to  three-quarters  of  an  inch  the  endo- 
metrium is  subjected  to  sharp  curettage,  as  shown  in  Figure  112.  In 
curettage  of  the  uterus  the  perineal  retractor  may  to  advantage  give 
place  to  the  index  and  middle  fingers  of  the  left  hand,  while  the 
operation  is  performed  by  means  of  the  curette  in  the  right  hand. 


Figure  110. 


Curettage.  First  step :  dorsal  position.  Cervix  exposed  by  perineal  retractor  in  right  hand 
of  nurse.  Uterus  drawn  down  by  vulsellum  forceps  in  left  hand  of  assistant.  Dilatation  begun 
by  small  dilator  in  right  hand  of  operator. 

After  thorough  curettage  the  uterus  is  flushed  out  with  sterile  water, 
Figure  113.  The  canula  used  for  this  purpose  may  be  a  simple  glass 
female  catheter  attached  to  a  rubber  tube.  This  tube  leads  from  a 
funnel  held  by  a  nurse  above  the  patient.  The  water  flows  from  the 
funnel  through  the  tube  and  the  glass  canula  into  the  uterus  until  the 
endometrium  is  irrigated  thorou2:hly.  During  the  irrigation  the 
canula  should  continually  be  withdrawn  and  reintroduced,  in  order  to 
prevent  the  possible  forcing  of  the  injected  fluid  into  the  Fallopian 
tubes.     Observe  the  forceps  fastened  to  the  rubber  tube.     This  is  a 


CHRONIC  ENDOMETRITIS. 

Figure  111. 


245 


Curettage.  Secoiiu  step:  dorsal  position.  Cervix  exposed  bv  perineal  retractor  in  rifrht 
hand  of  nurse.  Uterus  drawn  down  by  vulsellum  lorceps  in  left  liand  of  assistant.  Dilatation 
completed  by  Wathen  dilator  in  hands  of  operator. 

Figure  112. 


Curettage.  Third  step :  dorsal  position.  Perineum  retracted  by  two  fingers  of  operator  a 
left  hand.  Uterus  drawn  down  by  vulsellum  forceps  in  left  hand  of  assistant.  Endometrium 
curetted  by  sharp  curette  in  operator's  right  hand. 


246   INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

practical  device  for  reducing  the  size  of  the  rubber  tube  so  that  it  will 
fit  a  canula  or  catheter  of  smaller  size.  Not  infrequently  this  diifer- 
ence  in  calibre  between  the  tube  and  canula  gives  rise  to  considerable 
annoyance  during  an  operation,  which  may  be  obviated  much  more 
readily  and  quickly  by  means  of  the  forceps  thus  used  than  by  the 
common  means  of  tying  a  strong  cord  tightly  around  the  end  of  the 
tube  at  the  point  where  it  receives  the  canula. 

In  place  of  the  funnel  a  thoroughly  sterile  fountain-syringe  may  be 
used.  The  rubber  douche- bag  of  the  fountain-syringe  is  hung  usually 
on  a  hook  or  nail  at  some  point  near  to  and  above  the  patient.  Some- 
times, however,  in  private  practice  the  operation  is   delayed  because 

Figure  113. 


Curettage.  Fourth  step:  dorsal  position.  Perineum  retracted  by  two  fingers  of  operator  s 
,  left  hand.  Uterus  drawn  down  by  vulsellum  forceps  in  left  hand  of  assistant.  Endometrium 
irrigated  by  canula  inserted  into  rubber  tube  in  operator's  right  hand.  Figures  A  and  B  show 
a  fountain-syringe  attached  to  a  towel  by  means  of  pressure-forceps.  The  towel  may  be  fas- 
tened to  a  curtain  or  other  hanging  by  means  of  safety-pins.  The  fountain-syringe  may  be 
used  instead  of  the  funnel. 

; nothing  is  available  upon  which  to  hang  the  douche-bag.  To  over- 
come this  difficulty  the  bag  may  be  suspended  by  two  pairs  of  pressure- 
forceps,  as  shown  in  A  and  B,  Figure  113,  the  upper  forceps  being 
fastened  to  some  fabric  and  the  lower  forceps  to  the  douche-bag.  A 
shows  the  forceps  and  douche-bag  entire ;  B  shows  the  forceps  and 
upper  part  of  the  douche-bag  more  in  detail.  The  operation  is  per- 
formed usually  in  front  of  a  window.  Therefore  the  curtain  may  be 
used  upon  which  to  fasten  a  clean  towel  with  safety-pins.  The  upper 
forceps  may  be  attached  to  the  towel. 

The  irrigation  having  been  completed,  the  fingers  of  the  operator 


CHRONIC  ENDOMETRITIS. 


247 


are  removed  from  the  vagina,  the  perineum  again  retracted  l)y  means 
of  the  Simon  speculum  in  the  hand  of  the  nurse  or  assistant,  and  the 
uterus  swabbed  out  by  means  of  cotton  wound  on  a  dressing-forceps. 
Figure  114.  The  cotton  maybe  saturated  with  any  desired  disinfect- 
ant. A  saturated  sohition  of  iodine  crystals  in  95  per  cent,  of  carbolic 
acid  is  used  perhaps  most  frequently.  If  very  thorough  disinfection 
is  required,  40  per  cent,  formalin  may  be  employed.  Because  of  its 
destructive  power  formalin  should  be  used  with  care  lest  it  cause 
cicatricial  contraction.      In  order  to  prevent  the    application    from 


FiGUKE  114. 


Curettage.  Final  step :  dorsal  position.  Perineum  retracted  by  Simou  retractor  iu  rigui 
hand  of  nurse.  Uterus  drawn  down  by  vulsellum  forceps  in  left  hand  of  assistant.  Endo- 
metrium disinfected  by  cotton  wound  on  Emmet's  dressing-forceps  and  saturated  with  desired 
disinfectant.    Application  made  by  right  hand  of  operator. 

coming  in  contact  with  the  vagina,  it  is  well,  as  shown  in  the  Figure,  to 
protect  the  vaginal  mucosa  with  a  pledget  of  cotton  placed  between 
the  posterior  wall  of  the  cervix  and  the  perineal  retractor.  Before 
making  the  application  two  forceps  or  applicators  should  be  Mound 
with  absorbent  cotton,  and  one  should  be  pushed  into  the  uterine  canal 
with  the  cotton  dry  in  order  to  absorb  any  fluid  which  may  remain 
after  the  irrigation,  and  to  prevent  oozing,  for  if  the  application  be 
made  in  a  uterus  filled  with  blood  it  may  be  made  to  the  blood  and 
not  to  the  mucosa.  The  cotton  on  the  other  forceps  should  now  be 
dipped  in  the  desired  disinfectant  and  introduced  just  as  the  first  is 


248    INFECTIONS,  INFLAMMATIONS,  AND.  ALLIED  DISORDERS. 

withdrawn.  The  wad  of  cotton  posterior  to  the  cervix,  the  forceps 
used  in  making  the  application,  and  all  other  instruments  are  now 
removed.  No  dressing  is  required.  A  vaginal  douche  containing 
0.5  per  cent,  lysol  should  be  given  twice  daily  for  a  period  of  two 
weeks.     This  is  the  only  special  after-treatment. 

The  treatment  of  endometritis,  even  with  the  curette,  is  not  uni- 
formly successful.  Dilated  and  obstructed  blood-vessels  cannot 
always  be  restored  to  their  proper  calibre.  Disorganized  lym- 
phatics, nerves,  and  glands  do  not  always  resume  their  normal 
functions.  Regeneration  of  lost  structures  is  not  always  possible. 
In  these  respects  endometritis  offers  a  close  analogy  to  nasal  catarrh. 
In  the  glandular  forms  of  the  disease,  in  which  the  endometrium  yet 
retains  sufficient  integrity  to  insure  regeneration  of  the  glandular  and 
epithelial  structures,  the  sharp  curette  offers  both  a  symptomatic  and 
a  histological  cure.  When  the  disease  has  progressed  to  the  atrophic 
stage  of  interstitial  endometritis  and  the  endometrium  is  destroyed 
physiologically,  anatomical  cure  is  impossible  and  only  a  degree  of 
symptomatic  cure  is  possible.  When  endometritis  is  complicated  with 
extensive  chronic  metritis  and  obstinate  pelvic  infection,  the  uterine 
discharge  will  persist  regardless  of  curettage  or  of  any  other  intra- 
uterine treatment.  Under  such  conditions  hysterectomy  may  be  the 
only  means  of  relief.  Since  this  extreme  measure  might  be  indicated 
more  for  extra-uterine  than  for  uterine  inflammation,  the  considera- 
tion of  it  is  referred  to  the  subject  of  Inflammation  of  the  Uterine 
Appendages. 

Regeneration  of  Endometrium  after  Curettage. — Not  only  is  sharp 
curettage  efficient,  but  the  recent  investigations  of  Werth  and  others 
show  that  prompt  regeneration  of  the  uterine  mucosa  follows.  Studies 
of  the  recently  curetted  endometrium  show  that  the  work  often  is 
done  imperfectly,  and  that  large  portions  of  the  diseased  mucosa,  par- 
ticularly in  the  cornua  and  lateral  walls,  are  apparently  inaccessible 
to  the  ordinary  curette.  Special  small  curettes  should  be  used  there- 
fore for  these  parts. 

Werth  reports  histological  examinations  of  six  uteri  removed  at 
periods  varying  from  three  to  sixteen  days  after  curettage.  All  cases 
showed  unequal  results  of  the  scraping  on  the  various  parts  of  the 
uterine  mucosa.  Some  parts  were  untouched.  In  some  the  super- 
ficial layers  had  been  removed  and  the  deeper  layers  left,  and  in  other 
parts  the  muscularis  had  been  attacked.  The  mucosa  in  the  fundus 
and  in  the  lateral  portions  of  the  cavity  most  frequently  was  left 
intact.  The  abrasions  on  the  anterior  wall  were  deeper  than  on  the 
posterior.  They  were  also  deeper  in  the  lower  part  of  the  corpus 
near  the  internal  os.  This  is  explained  by  the  convergence  of  the 
downward  strokes  of  the  curette.  Except  in  places  where  the  mus- 
cularis had  been  injured  by  the  curette,  the  entire  lining  of  the  uterus 
was  covered  with  new  mucosa,  the  glands  opening  freely  on  a  surface 
of  unbroken  superficial  epithelium.  This  young  mucosa  was  charac- 
terized by  great  preponderance  of  fibrillary  connective  tissue  over 
the  connective  tissue  of  the  stroma.  The  regenerating  tissue  was 
supplied  with  blood-vessels  which  grew  out  of  the  muscularis  or  out 


CHRONIC  ENDOMETRITIS.  249 

of  the  remaining  mucosa.  The  vessels  were  surrounded  with  a  broad 
mantle  of  fibrillary  connective  tissue  which  followed  their  ramifications 
almost  to  the  surface  of  the  mucosa. 

The  glands  were  regenerated  from  their  deeper  portions  which  the 
curette  had  spared,  especially  from  those  which  were  situated  where 
the  mucosa  dips  deep  down  into  the  muscularis  ;  they  grew  out 
toward  the  surface  together  with  the  surrounding  blood-vessels  and 
fibrillary  connective  tissue.  The  surrounding  stroma  was  observed 
frequently  to  grow  more  rapidly  than  the  glands,  and  to  give  a  some- 
what irregular,  jagged  contour  to  the  regenerated  endometrium.  The 
superficial  epithelium  was  found  to  be  regenerated  principally  from 
that  of  the  glands.  In  some  places  the  young  epithelial  cells  were 
found  flattened  and  enlarged.  In  the  later  stages  of  the  regen- 
eration of  the  mucosa  the  excess  of  fibrillary  connective  tissue  was 
observed  to  disappear  by  hyaline  degeneration.  This  process  on  the 
fifth  day  after  curettage  was  visible  in  the  subepithelial  layers ;  and 
on  the  tenth  day  only  a  few  fibrillse  were  left  in  the  superficial 
stroma  ;  in  their  places  were  large,  spindle-shaped  cells,  with  several 
processes  of  protoplasm.  Only  in  those  parts  where  the  muscularis 
had  been  abraded  did  there  exist  a  condition  resembling  that  of 
granulation-tissue. 


CHAPTEK  XYIII. 

CHRONIC   METRITIS. 

Cheoxtc  metritis — usually  understood  to  mean  inflammation  of 
the  uterine  muscularis,  a  condition  more  accurately  described  by  the 
word  myometritis — is  taken  here  in  its  broader  literal  sense,  and  is 
used  to  designate  chronic  inflammation  of  the  uterus  as  a  whole,  and 
to  include  therefore  eudocervicitis,  endometritis,  myometritis,  and 
perimetritis.  The  various  parts  of  the  uterus — i.  e.,  the  endometrium, 
myometrium,  perimetrium,  corpus,  and  cervix — never  are  involved  in 
sharply  defined  areas  of  disease,  although  any  one  of  them  may  be  the 
specially  affected  part  of  the  diseased  organ.  The  disease  is  commonly 
the  consequence  of  endometritis  and  coincident  with  it.  Infection  of 
the  uterus  as  observed  by  the  clinician,  except  acute  gonorrhoeal  and 
puerperal  metritis,  is  generally  chronic. 

The  striking  phenomena  of  acute  metritis  are  the  active  infective 
and  inflammatory  processes.  The  term  chronic  metritis  stands  not  so 
much  for  definite  processes  as  for  certain  chronic  changes,  more  or 
less  permanent,  in  the  quantity  and  quality  of  the  glandular  elements, 
muscularis,  blood-vessels,  lymphatics,  and  connective  tissue.  These 
changes  are  usually  hypertrophic,  hyperplastic,  or  atrophic.  They 
have  been  the  subject  of  a  long  and  unsatisfactory  discussion,  and 
have  been  designated  variously  as  infective,  inflammatory,  irritative, 
subinflammatory,  and  congestive.  Although  the  changes  under  con- 
sideration may  not  always  conform  to  the  strict  idea  of  inflammation, 
there  is  yet  a  propriety  in  calling  them  inflammatory,  because  the 
essential  element  of  inflammation — round-cell  infiltration — is  usually 
present.  In  chronic  inflammations  migration  of  these  cells  occurs, 
if  at  all,  more  slowly  than  in  acute  inflammation. 

Etiology  of  Chronic  Metritis. 

The  chief  predisposing  causes  are  these  : 

Acute  metritis,  eudocervicitis,  and  endometritis. 

Septic  puerperium  and  abortions. 

Infection  following  operations  and  examinations. 

Uterine  tumors. 

Frequent  parturition. 

Uterine  displacements. 

Excessive  venery. 
The  bacterial   exciting  causes  are  the  same  as  in  acute  metritis, 
see  Chapter  X.     Chronic  metritis  frequently  is  associated  with  ob- 
structed circulation  in  the  abdominal  viscera,  especially  the  liver,  and 
with  rheumatism,  gout,  lithsemia,  and  cholaemia. 

250 


CHRONIC  METRITIS.  251 

Pathology  of  Chronic  Metritis. 

Since  chronic  metritis  is  the  sum  of  all  the  inflammations  of  the 
uterine  mucosa,  uterine  muscularis,  and  uterine  peritoneum,  it  follows 
that  the  pathology  of  it  must  embrace  : 

I.  Chronic  changes  in  the  mucosa — endometritis  and  endocer- 
vicitis — of  which  the  pathology  has  been  described  in  Chapter  XV. 
and  XVI. 

II.  Chronic  changes  in  the  perimetrium — peritonitis — which  will 
be  described  in  the  chapter  on  Pelvic  Peritonitis. 

III.  Chronic  changes  in  the  muscularis  w'hich  occur  in  two  forms : 

1.  Hypertrophic. 

2.  Interstitial. 

1.  Pathology  of  Hypertrophic  Metritis. — In  this  form  of 
chronic  metritis  all  the  histological  elements  are  increased.  Hyper- 
trophy of  puerperal  origin  should  be  distinguished  from  that  of  non- 
puerperal origin. 

Puerperal  Hypertrophy,  commonly  known  as  suhinvolution,  is  pro- 
duced as  follows :  The  muscular  elements,  enormously  increased 
during  the  evolution  of  pregnancy,  fail  to  undergo  the  normal  physio- 
logical degeneration  and  absorption  after  labor.  The  connective  tissue 
also  remains  superabundant.  The  lymph-vessels  and  blood-vessels 
continue  large,  full,  and  stagnant.  The  uterine  walls  are  thickened 
from  congestion  and  infiltration.  The  uterus  is  not  always  uniformly 
enlarged — that  is,  the  hypertrophy  may  pertain  especially  to  the  cer- 
vix or  to  the  corpus  uteri.  The  uterus  may  be  twice  as  large  as 
normal,  and  the  canal  may  measure  three  or  four  inches.  The  organ 
remains  soft  and  mobile.  This  flexibility  accounts  for  the  fact  that 
many  uterine  flexures  date  from  the  puerperium.  Subinvolution  may 
therefore  he  defined  as  the  failure  of  "physiological  hypertrophy  to  subside 
after  labor. 

Non-puerperal  Hypertrophy  is  pathological  from  the  beginning,  and 
may  occur  in  women  who  have  never  been  pregnant.  It  is  sometimes 
clinically  impossible  to  distinguish  between  the  puerperal  and  non- 
puerperal varieties. 

Great  hypertrophic  elongation  of  the  supravaginal  and  enlarge- 
ment of  the  infravaginal  portions  of  the  cervix,  wath  descent,  are 
described  in  the  chapters  on  Laceration  of  the  Cervix  and  Displace- 
ments. Sometimes  hypertrophic  enlargement  pertains  chiefly  to  the 
corpus  uteri,  sometimes  to  the  cervix  ;  or  it  may  involve  uniformly 
the  entire  organ.  Hypertrophy  of  the  cervix  often  is  confounded 
with  laceration.  The  symptoms,  like  the  causes,  are  almost  identical 
with  those  of  the  associated  endometritis.  In  the  absence  of  marked 
perimetritis,  or  parametritis,  the  uterus  is  not  very  sensitive  to  the  touch. 
Downward  displacement  from  increased  weight  is  usual.  Perverted 
menstrual  and  other  functions  are  the  same  as  in  endometritis. 

The  prognosis  is  much  more  favorable  for  puerperal  than  for  non- 
puerperal myometritis — i.  e.,  subinvolution,  if  non-infectious,  is  often 
only  temporary.  The  disease  is  apt  to  be  obstinate  and  destructive 
in  proportion  as  the  infectious  element  predominates. 


252    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

2.  Pathology  of  Interstitial  or  Cirrhotic  Metritis. — In  this 
form  of  metritis,  sometimes  called  areolar  hyjierplasia,  there  are  increase 
of  connective  and  loss  of  muscular  tissue.  The  muscular  wall  is  pale 
and  indurated.  The  microscope  will  show  hyperplasia  of  intermus- 
cular connective  tissue,  corresponding  atrophy  of  muscle-fibres,  and 
contraction  of  blood-vessels  as  already  stated.  The  chronic  changes 
in  these  various  parts  may  be  the  outcome  of  acute  processes  already 
described  under  acute  metritis ;  or  there  may  have  been  no  clearly 
marked  acute  stage — i.  e.,  the  disease,  at  least  apparently,  may  have 
been  chronic  or  subacute  from  the  beginning. 


FlfitlRE  115. 


So-called  hypertrophic  elongation  of  the  supravaginal  portion  of  the  cervix— rare  except 
as  a  posi-operative  or  post-mortem  condition.  The  cervix  often  becomes  elongated  by  traction 
during  the  removal  of  the  uterus. 

Hyperplasia  of  connective  tissue,  whether  puerperal  or  non- 
puerperal, may  follow  hypertrophy  or  may  develop  independently  of 
it.  This  form  of  the  disease  often  results  in  a  sort  of  pathological 
involution,  with  the  following  permanent  changes  :  The  lymph- vessels 
and  blood-vessels  shrink  and  wither,  the  nutrition  of  the  muscular 
elements  is  cut  off,  and  they  disappear  as  if  crowded  out  by  the  in- 
creasing connective  tissue ;  the  uterus  now  becomes  hard  and  ansemic  ; 
it  still  may  remain  large  from  the  superabundant  connective  tissue,  but 
finally  this  may  contract  and,  cicatrix  like,  reduce  the  organ  even 
below  its  normal  size.     The  result  of  these  changes  are  great  uterine 


CHRONIC  METRITIS. 


253 


irritation  and  pelvic  pain.     The  whole  organ  with  its  appendages  and 
adjacent  structures  is  in  a  state  of  permanent  malnutrition. 

In  connection  with  the  atrophic  changes  of  interstitial  and  cir- 
rhotic metritis  may  be  mentioned  two  special  forms  of  atrophy  :  puer- 
peral atrophy — superinvolution — a  certain  form  of  non-puerperal 
atrophy  and  arteriosclerosis. 

Puerperal  Atrophy — superinvolution — is  the  direct  opposite  of  sub- 
involution. In  superinvolution  the  process  of  degeneration  and 
absorption  after  labor  passes  beyond  the  physiological  limits,  and  the 
uterus  shrinks  below  the  normal  size  and  becomes  soft  and  excessively 
mobile.     The  condition  resembles  senile  atrophy  of  the  menopause. 

Figure  116. 


Hypertrophy  of  the  cervix  uteri.    The  expansion  of   the  cervix  is  due  partly  to  eversion 
of  intra-uterine  mucosa  consequent  on  laceration  of  the  cervix. 

Apparently  there  are  two  distinct  varieties  of  superinvolution — one 
temporary,  the  other  permanent.  The  two  forms  are  differentiated 
by  the  fact  of  a  normal  puerperium,  usually  wath  prolonged  lactation, 
in  the  temporary  form,  and  by  the  history  of  a  septic  puerperium  in 
the  permanent  variety.  In  the  latter  case  one  or  more  of  the  repro- 
ductive organs  or  parts  thereof — i.  e.,  the  endometrium,  myometrium, 
and  the  uterine  appendages — become  infected  and  in  a  physiological 
sense  destroyed.  In  the  temporary  variety  spontaneous  recovery  may 
occur  and  the  woman  again  may  bear  children.  In  the  destructive 
form  there  is  permanent  atrophy  of  all  the  structures  involved. 
Menstruation,  if  it   returns  at  all,  is  scanty  and  generally  painful. 


254    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Immediate  amenorrhoea  is  the  rule.     There  is  sometimes  a  painful 
mohmen  in  place  of  menstruation. 

Non-puerperal  Atrophy. — There  is  another  class  of  cases  in  which 
atrophy  of  the  reproductive  organs  occurs  independently  of  parturi- 
tion. This  form  of  atrophy  is  generally  the  result  of  chronic  wasting 
disease,  like  tuberculosis  and  diabetes  ;  or  of  acute  infectious  disease, 
like  scarlatina,  rubeola,  and  enteric  fever.  There  is  always  cessation 
of  menstruation.  This  is  a  conservative  effort  of  nature  to  save  the 
patient's  blood  and  strength.  Unfortunately,  however,  the  ill-health 
of  the  patient  often  is  attributed  wrongly  to  the  amenorrhoea,  and 

FiGUEE   117. 


Hypertrophy  of  the  corpus  uteri:  observe  the  great  size  of  the  corpus  relative  to  that  of 

the  cervix. 

treatment  designed  to  stimulate  and  re-establish  menstruation  some- 
times is  used.  By  such  means  the  woman's  vitality  may  still  further 
be  exhausted.  The  above  facts  from  the  therapeutic  standpoint,  espe- 
cially in  tubercular  and  other  wasting  diseases,  are  very  significant. 
Clearly  the  treatment  should  not  be  local,  but  systemic. 

Superinvolution  and  non-puerperal  atrophy  are  rare ;  the  causes 
are  obscure  ;  the  precise  relation  of  inflammation  to  them  is  unknown. 
Except  in  the  temporary  non-infectious  form  already  mentioned, 
recovery  rarely  or  never  takes  place. 

Arteriosclerosis. — Chronic  metritis  in  advanced  years  is  asso- 
ciated not  imcommonly  with  sclerosis  of  the  uterine  arteries,  and  in 
some   instances   with  calcareous   degeneration  of  the  vessels ;   theise 


CHRONIC  METRITIS. 


255 


changes  may  be  looked  upon  as  senile  degeneration,  are  not  therefore 
always,  in  the  strict  sense,  pathological,  but  may  be  rather  the  natural 
changes  of  old  age. 

The  Physical  Signs  of  Chronic  Metritis. 

1.  The  uterus  is  enlarged  symmetrically,  and  on  bimanual  exami- 
nation, in  the  later  stages,  is  harder  and  firmer  to  ])ressure  than  nor- 
mal. Atrophic  changes  later  may  cause  the  uterus  to  contract  to 
rudimentary  size. 

2.  Tenderness  on  pressure  is  not  very  marked  unless  there  is  com- 
plicating inflammation  of  the  uterine  appendages. 

3.  The  uterus  may  be  freely  movable  or  fixed  by  adhesions. 

4.  The  uterus  may  be  displaced  ;  and,  if  so,  the  deviation  is  apt  to  be 
anteversion  and  descent ;  this  gives  rise  to  vesical  and  rectal  irritation. 

5.  Enlargement  of  the  uterine  cavity  may  be  demonstrated  by 
passing  the  sound. 

The  Symptoms  and  Diagnosis  of  Chronic  Metritis. 

1.  The  temperature  is  normal  or  only  slightly  elevated. 

2.  Pain  is  not  acute  ;  there  is  usually  a  sense  of  aching,  pressure, 
weight  and  dragging  in  the  back,  hypogastrium,  and  thighs. 

3.  Menstrual  disturbances,  such  as  menorrhagia,  intermenstrual 
uterine  hemorrhages,  and  dysmenorrhoea,  singly  or  combined,  are 
commonly  present. 

4.  Sterility,  which  may  be  due  to  coexisting  lesions,  is  usual. 

5.  Defecation  and  urination  in  most  cases  are  painful. 

6.  Reflex  and  sympathetic  disturbances  of  extrapelvic  organs, 
especially  the  organs  of  digestion,  and  faulty  general  nutrition,  are 
generally  present. 


Differential  Diagnosis  of  Chronic  Metritis. 

The  differential  signs  are  between  metritis,  small  fibroid  tumors, 
and  early  pregnancy. 


Chronic  metritis. 

1.  Menorrhagia  and  intra- 
menstrual  uterine  hemor- 
rhages, not  invariable. 

2.  No  signs  of  pregnancy. 


3.  Uterus  hard  and  regular 
In  outline. 

4.  Uterus  commonly  in 
pathological  anteversion  and 
descent ;  may  be  in  retrover- 
sion. 


Small  fibroid  tumors. 

1.  Menorrhagia  and  uterine 
hemorrhage  the  rule. 

2.  No  signs  of  pregnancy. 


3.  Uterus  hard  and  irregu- 
lar in  outline. 

4.  Uterus  liable  to  be  dis- 
placed In  any  direction  ac- 
cording to  the  mechanical 
influence  of  the  fibroids. 


Early  pregnancy. 
1.  Ameuorrhoea. 


2.  Signs  of  early  pregnancy: 

'(.  Morning  sickness. 

b.  Enlarged  breasts. 

c.  Blue  discoloration  of 

vaginal  mucosa. 

d.  Softening  of  the  cer- 

vix uteri. 

e.  Hegar's    symptom    of 

narrow  supravaginal 
portion  of  the  cervix. 
/.  Rhythmical  uterine 
contraction  under 
the  palpating  hand. 

3.  Uterus  soft  and  regular  in 
outline;  may  momentarily  con- 
tract and  harden  on  handling. 

4.  Uterus  commonly  ante- 
verted. 


256    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

The  least  doubt  as  to  the  existence  of  pregnancy  should  lead  one 
to  await  developments.  Under  no  circumstances  should  the  sound 
be  passed  if  pregnancy  is  a  possibility. 

Treatment  of  Chronic  Metritis. 

The  treatment  of  chronic  metritis  is  that  of  the  associated  lesions. 
The  reader  is  referred  therefore  to  the  treatment  of  endocervicitis, 
endometritis,  perimetritis,  parametritis,  and  inflammation  of  the 
uterine  appendages. 

Numerous  operations  to  reduce  the  size  and  weight  of  the  uterus 
have  been  devised,  such  as  amputation  and  resection  of  the  cervix 
uteri ;  but  as  already  set  forth,  enlargement  of  the  cervix  is  generally 
rather  apparent  than  real,  and  is  due  to  the  results  of  laceration.  See 
Chapter  XLII.  for  Emmet's  operation  and  Schroeder's  operation. 
As  explained  in  the  preceding  chapter,  when  the  wall  of  the  uterus 
becomes  so  infected  that  it  resembles  the  wall  of  an  abscess-cavity  the 
organ  should  be  removed.  Supravaginal  hysterectomy  sometimes  is 
indicated  by  an  enormously  enlarged  uterus,  especially  when  the 
enlargement  is  associated  with  disabling  displacement.  See  operation 
for  supravaginal  hysteromyomectomy  in  Chapter  XXVII. 


CHAPTEK   XIX. 

PELVIC  INFLAMMATION. 

ROUTES  OF  INFECTION— GENERAL    ETIOLOGY  AND  SIGNIFI- 
CANCE OF  PELVIC  INFLAMMATION. 

Infection  of  the  uterus,  as  set  forth  iu  the  preceding  chapters, 
may  extend  from  the  uterine  mucosa  to  the  surrounding  lymph- 
channels,  veins,  cellular  tissue.  Fallopian  tubes,  ovaries,  and  peri- 
toneum. The  subject  of  pelvic  inflammation  therefore  includes 
lymphangitis,  phlebitis,  cellulitis,  salpingitis,  ovaritis,  and  pelvic 
peritonitis. 

Routes  of  Infection. 

Inflammation  around  the  uterus,  as  set  forth  in  Chapter  X.,  occurs 
frequently  by  the  extension  of  infection  in  the  uterine  mucosa  to 
the  outlying  structures,  less  frequently  from  infection  in  the  vagina, 
bladder,  or  rectum,  and  not  seldom  from  extrapelvic  organs.  When 
it  spreads  from  the  uterine  mucosa  it  passes  to  the  outlying  structures 
by  one  of  two  routes  : 

1.  Continuity  of  uterine  and  tubal  mucosa. 

2.  The  lymph-vessels  and  blood-vessels  of  the  uterine  muscularis 

and  of  the  para-uterine  connective  tissue. 

Route  by  Continuity  of  Mucosa. — Transmission  by  continuity 
of  mucosa  does  not  invariably  involve  all  the  epithelial  surfaces  over 
which  the  infection  has  passed.  It  is  probably  possible,  although  not 
usual,  for  infection  to  travel  from  the  endometrium  to  the  abdominal 
end  of  the  tube  without  intervening  infection  of  the  uterine  end. 
Even  though  the  uterine  end  has  been  infected,  it  may,  owing  to  its 
smoother  surface  and  greater  resistance,  have  recovered,  leaving  the 
disease  only  at  the  abdominal  end. 

Route  by  Lymph-vessels  and  Blood-vessels. — The  lymph-channel 
may  be  the  mere  carrier  of  infection,  and  may  itself  show  no  trace  of 
inflammation,  or  it  may  be  inflamed  throughout ;  this  is  because  the 
bacteria,  by  whatever  route  carried,  may  colonize  only  at  points  of 
least  resistance ;  freedom  from  infection  in  the  vessels  therefore  does 
not  prove  that  infection  has  not  passed  through  them. 

Route  from  Extrapelvic  Organs. — Purulent  salpingitis  spread- 
ing from  purulent  appendicitis  and  tubercular  salpingitis  extending 
from  tubercular  peritonitis  have  been  observed  very  frequently ;  these 
are  examples  of  infection  from  organs  outside  the  pelvis. 

17  857 


258    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Etiology  of  Pelvic  Inflammation. 

Since  extra-uterine  pelvic  infection  usually  originates  in  the  endo- 
metrium, the  causes  for  the  most  part  will  correspond  with  those  of 
endometritis  ;  the  infection  may  arise  also  from  the  intestines,  bladder, 
peritoneum,  vagina,  or  from  the  general  circulation  as  a  sequel  of  the 
acute  infectious  diseases.  Pelvic  hsematocele  may  become  the  seat  of 
infection  and  be  the  predisposing  cause  of  a  pelvic  abscess.  See 
Tubal  Pregnancy. 

Laceration  of  the  perineum  and  cervix,  and  other  traumatisms  of 
parturition  and  of  surgery,  may  open  the  way  for  the  entrance  of  in- 
fection through  the  blood-  and  lymph-channels.  The  puerperal  and 
traumatic  infections  more  frequently  take  this  route.  Infection  of 
lymph-vessels  and  blood-vessels  may  be  carried  to  the  uterine  append- 
ages from  external  cervicitis.  The  micro-organisms  of  infectious  dis- 
eases, which  have  been  found  in  the  genitals,  are  introduced  most 
frequently  by  uncleanly  operations,  local  treatment,  and  examinations. 
Chief  among  these  micro-organisms  are  the  following : 

Gonococcus.  Diphtheria  bacillus. 

Colon  bacillus.  Typhoid  bacillus. 

Tubercle  bacillus.  Pneumococcus. 

Streptococcus  pyogenes.  Actinomyces. 

Staphylococcus  pyogenes  albus,  citreus,  and  aureus. 


Significance  of  Inflammation. 

Extra-uterine  pelvic  infection,  whether  it  passes  from  the  uterus 
by  the  Fallopian  tubes  to  the  peritoneum  by  continuity  of  surface ;  or 
by  way  of  the  lymph-chaimels  or  veins  in  the  pelvic  cellular  tissue, 
may  be  arrested,  in  the  first  route,  by  inflammatory  occlusion  of  the 
tube ;  in  the  second  route  by  thrombic  plugging  of  the  vessels. 
In  the  one  case  the  infection  may  be  confined  to  the  tube  (salpingitis), 
in  the  other  to  the  cellular  tissue  around  the  vessels  (perilymphangitis 
or  periphlebetis — i.  e.,  cellulitis).  The  infection  if  not  so  arrested 
may  pass  to  the  pelvic  cavity  and  give  rise  to  peritonitis.  The  inflam- 
matory process  then  may  localize  itself  by  setting  up  peritoneal  adhe- 
sions and  form  a  protective  wall  against  general  peritonitis.  If 
neither  one  of  these  protective  processes  takes  place,  then  the  infection 
speedily  may  involve  the  whole  peritoneum  and  the  toxins  may  be 
increased  rapidly  and  poured  in  fatal  quantities  from  the  peritoneal 
surfaces  into  the  general  circulation. 

We  are  familiar  with  the  profound  depression  of  the  nervous  sys- 
tem, the  continued  nausea,  the  anxious  facies,  the  paretic  and  dis- 
tended bowels,  and  the  tympanites,  which  go  to  make  up  the  symptom- 
group  of  general  peritonitis.  These  grave  symptoms  of  infection  so 
often  attributed  wrongly  to  the  inflammatory  process,  are  rather  the 
result  of  the  profound  toxaemia  which  the  inflammation  is  striving 
unsuccessfully  to  shut  off  from  the  general  circulation.     If,  on  the 


PELVIC  INFLAMMATION.  259 

other  hand,  a  protective  process  becomes  effective,  the  result  may  be 
an  almost  overwhelming  inflammation  which  may  for  the  most  part 
be  confined  so  that  the  infection  will  spend  its  force  within  the  narrow 
limits  of  the  infected  territory.  The  localized  infective  process  may 
be  so  intense  as  to  end  in  permanent  impairment  of  the  pelvic  nutrition 
and  in  chronic  invalidism  ;  but  the  involved  tissue  has  taken  the 
brunt  of  the  attack,  sacrificed  itself,  and  perchance  saved  the  life  of 
the  woman. 


CHAPTER    XX. 

PELVIC  CELLULITIS. 

Before  reading  this  chapter  on  cellulitis  the  student  is  requested 
to  consult  the  previous  paragraphs  on  the  Significance  of  Inflammation. 

Anatomy. 

An  abundance  of  loose  cellular  tissue  binds  all  the  pelvic  viscera 
together.  It  is  continuous  with  the  cellular  tissue  of  the  uterus  and 
its  appendages,  and  is  found  in  large  quantities  especially  in  the  broad 
ligaments ;  it  is  the  medium  through  which  the  lymph-  and  blood- 
vessels, and  nerves  connect  the  uterus  with  its  appendages,  and  bring 
them  all  into  close  anatomical,  physiological,  and  pathological  rela- 
tions. The  cellular  tissue,  and  particularly  that  of  the  broad  liga- 
ments, becomes  therefore  a  most  significant  factor  in  pelvic  infection. 
Cellular  tissue  of  the  pelvis  binds  the  various  pelvic  organs  together 
and  fills  nearly  all  the  space  in  the  pelvis  not  occupied  by  them ;  it 
exists  in  great  quantities  around  the  uterus,  vagina,  rectum,  bladder, 
and  the  psoas  and  iliacus  muscles,  and  furnishes,  therefore,  an  abun- 
dance of  material  for  the  development  of  cellulitis. 

Exception  sometimes  has  been  taken  to  the  name  cellulitis,  since 
all  tissues  are  cellular,  and  since  therefore,  in  the  wide  sense,  all 
inflammation  is  cellulitis.  The  word  is  used  here  in  accordance  with 
established  usage,  and  is  limited  to  inflammation  of  the  cellular  tissue 
around  the  uterus  and  vagina,  more  especially  that  between  the  folds 
of  the  broad  ligaments.  The  term  parametritis  is  too  restricted,  since 
the  disease  may  occur  in  the  lower  regions  of  the  pelvis  around  the 
vagina  and  bowel.  Cellulitis  usually  is  associated  with  some  degree 
of  peritonitis  and  therefore  is  related  to  it  much  as  pneumonia  is 
related  to  pleuritis. 

Etiology  of  Pelvic  Cellulitis. 

Cellulitis,  or,  as  it  commonly  is  called,  pelvic  parametritis,  is 
usually  of  puerperal  origin  ;  the  causes  therefore  are  largely  iden- 
tical with  those  of  puerperal  infection.  The  etiology  in  general  is  con- 
sidered in  Chapter  X.  The  most  frequent  bacteria  in  cellulitis  are 
the  common  pus  cocci.  The  gonococcus  has  been  found  in  connective 
tissue  and  in  the  lymph-vessels  of  the  parametria.  The  source  of  the 
infection  is  usually  the  inflamed  uterus  ;  but  it  may  arise  in  the 
perineum,  vagina,  bladder,  or  rectum.  The  infected  rectum,  urethra, 
and  bladder  are  frequent  sources  of  cellulitis  in  men.  Unclean  thera- 
peutic appliances,  septic  manipulations  generally,  and   traumatisms, 

260 


PELVIC  CELLULITIS.  261 

especially  those  of  parturition,  open  the  way  for  the  entrance  of  the 
bacteria. 

Pathology  and  Pathological  Anatomy  of  Pelvic  Cellulitis. 

Infection  reaches  the  cellular  tissue  by  way  of  the  lymph-vessels 
and  veins  and  may  produce  lymphangitis  or  phlebitis — that  is,  inflam- 
mation in  the  walls  of  the  vessels.  The  progress  of  the  infection 
may  now  be  checked  by  thrombic  plugging  of  the  vessels  and  destruc- 
tion of  their  walls.  The  infection  then  will  spread  to  the  surrounding 
structures  producing  perilymphangitis  or  periphlebitis  and  involving 
the  tissue  around  the  vessels,  which  is  cellular  or  connective  tissue. 
The  disease  in  its  full  development  therefore  is  cellulitis.  Hence  to 
define  cellulitis  as  jierilymphangitis  or  periphlebitis  would  be  strictly 
accurate. 

Cellulitis,  like  other  inflammations,  is  divided  into  three  stages  : 
1,  congestion  ;  ^,  effusion  ;  and  3,  suppuration.  The  disease  may  ter- 
minate with  either  of  these  stages.  If  it  goes  to  effusion,  it  may  end 
in  resolution  and  complete  recovery,  or  continue  as  chronic  cellulitis, 
or  go  on  to  suppuration  and  form  a  pelvic  abscess. 

The  blood-  and  lymph-vessels  here  and  there  are  plugged  with 
firm  inflammatory  thromboses.  If  resolution  does  not  follow,  the 
thromboses  break  down  and  the  corresponding  spaces  are  filled  with 
pus.  The  infection  spreads  from  these  small  collections,  which  are, 
in  fact,  small  abscesses,  and  frequently  leads  to  the  formation  of  single 
or  multiple  abscesses  in  the  broad  ligaments.  These  abscesses  creep 
along  the  meshes  of  the  loose  connective  tissue,  avoiding  firmer  and 
stronger  parts,  and  unless  opened  by  incision  may  burst  into  the  vagina, 
bladder,  urethra,  or  intestine,  or  above  Poupart's  ligament,  rarely 
below  it,  or  into  the  labia  majora,  peritoneal  cavity,  or  lumbar  region, 
or  through  the  obturator,  sacrosciatic,  or  saphenous  openings.  Ab- 
scesses of  cellulitic  origin  most  frequently  burst  into  the  vagina  ;  those 
of  tubal  origin,  especially  if  surrounded  by  peritoneum,  are  more  apt 
to  break  into  the  bowel  or  bladder.  The  bursting  of  an  abscess 
through  the  cutaneous  surface  or  into  an  organ  which  affords  ready 
drainage  may,  if  not  followed  by  fresh  infection,  result  in  spontaneous 
cure.  The  breaking  of  an  abscess  into  the  peritoneum  may  set  up 
fatal  peritonitis. 

In  very  severe  cases,  with  extensive  invasion  of  the  lymphatics, 
the  whole  cellular  tissue  of  the  pelvis  may  be  involved  in  paracystitis, 
paracolpitis,  paraproctitis,  parametritis,  salpingitis,  and  ovaritis. 
Such  infection  usually  results  in  multiple  abscesses  and  great  systemic 
disturbance.  It  is  known  as  the  erysipelas  malignum  internum  of 
Virchow,  or  diffuse  cellulitis  of  Pozzi.  There  may  also  be  hemor- 
rhages from  destruction  of  the  blood-vessels.  The  clinical  picture  in 
these  cases  is  that  of  an  acute  general  septicseraia.  The  infection 
may  result  in  general  peritonitis,  and  accumulations  of  pus  may  form 
throughout  the  abdominal  cavity.  The  condition  is  rare  and  the 
rate  of  mortality  high. 

Formerly  cellulitis  was  considered  the  central  lesion  in  pelvic  in- 


262    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

flamraation.  Salpingitis,  ovaritis,  and  peritonitis  scarcely  were  recog- 
nized as  surgical  diseases.  A  great  advance  was  made  in  practical  pelvic 
pathology  when  Battey,  Hegar,  Tait,  and  others  showed  the  vastly 
greater  relative  importance,  from  the  surgical  standpoint  at  least,  of 
tubal  inflammation.  When  purulent  accumulations  in  the  pelvis  were 
attributed  commonly  to  cellulitis,  and  therefore  were  left  to  them- 
selves or  treated  by  incision  and  drainage  into  the  vagina,  the  failures 
were  many  and  unexplained.  As  soon,  however,  as  the  majority  of 
those  abscesses  were  recognized  as  accumulations  of  pus  in  the 
Fallopian  tubes  it  was  easy  to  understand  why  incision  and  drainage 
Avere  followed  so  often  by  failure.  It  was  because  the  tube  is  lined 
with  mucous  membrane  and  because  chronic  suppuration  of  mucous 
surfaces,  even  when  drained,  is  most  intractable.  On  the  other  hand, 
a  cellulitis  abscess  surrounded  by  cellular  tissue,  when  emptied  is  apt 
to  close  spontaneously.  Pelvic  cellulitis  therefore,  unless  complicated 
by  tubal  communication,  either  terminates  rapidly  by  resolution  with 
complete  recovery  ;  or,  if  suppuration  occur,  it  empties  spontaneously 
or  is  evacuated  by  incision,  and  like  a  furuncle,  wdiich  it  resembles, 
promptly  disappears ;  hence  the  cellulitis  abscess,  unless  of  tubal 
origin,  seldom  becomes  chronic,  and  therefore  has  little  or  no  part  in 
the  more  familiar  chronic  pelvic  suppuration  for  which  the  uterine 
appendages  and  sometimes  also  the  uterus  have  to  be  removed. 

Clinical  experience  shows  pelvic  suppuration  to  be  primarily 
almost  always  in  the  tube ;  rarely  in  the  cellular  tissue  below ;  and 
if  perchance  an  abscess  be  found  there,  it  usually  gives  evidence  of 
having  burst  from  the  tube  into  the  broad  ligament. 

The  above  facts  have  led  to  a  tendency  of  late  years,  especially 
among  the  laparotomists,  to  deny  the  existence  of  pelvic  cellulitis, 
and  to  declare  that  an  abscess  in  the  broad  ligament  is  there  only 
when  a  previous  infection  of  the  Fallopian  tube  has  forced  its  way 
through  the  mesosalpinx  into  the  parametrium.  In  this  connection 
let  us  remember  that  the  disease  occurs  in  men,  wdio  have  no  Fallopian 
tubes,  and  that  cellular  tissue  in  the  pelvis  must  be  subject  to  the 
same  laws  of  infection  as  in  other  parts  of  the  body.  The  question, 
however,  is  not  settled  by  a  priori  reasoning.  Post-mortem  studies 
prove  the  frequent  existence  of  acute  cellulitis  abscess  not  only  by 
rupture  of  a  sactosalpinx  into  the  parametric  cellular  tissue,  but  also 
by  the  direct  infection  of  the  parametria  by  the  lymphatic  or  venous 
route. 

Pelvic  cellulitis  gives  rise  to  numerous  displacements  and  distor- 
tions of  the  pelvic  organs,  chief  among  which  are  : 

a.  Uterus  drawn  forward,  backward,  or  to  either  side. 
6.  Ovaries  and  tubes  displaced  and  fixed. 

c.  Bladder  displaced  or  distorted. 

d.  Rectum  constricted  (rarely). 

Chronic  Atrophic  Cellulitis. — There  is  a  form  of  chronic  cellu- 
litis, described  by  Freund,  characterized  by  atrophic  changes  analo- 
gous to  cirrhotic  disease  in  other  organs.  This  disease  may  originate 
in  inflammation  of  the  uterus,  bladder,  or  rectum,  and  is  especially 
apt    to  include    chronic  atrophic  pericystitis  and  periproctitis — i.  e., 


PELVIC  CELLULITIS.  263 

infliimmation  of  the  connective  tissue  around  the  rectum  and  bladder 
witli  resultant  contraction  of  these  viscera  and  shortening  of  the  vagina. 

The  atrophic  contracted  cicatrix-like  cellular  tissue  may  cause 
excessive  versions  and  flexions  of  the  uterus.  Since,  however,  the 
symptoms  would  be  due  rather  to  the  cirrhotic  disease  than  to  the 
uterine  deviations,  mechanical  support  would  be  of  little  or  no  value. 
Perineuritis ;  neuritis ;  destruction  of  blood-  and  lymph-vessels ; 
pinching  of  the  nerves,  lymphatics,  blood-vessels,  and  ureters  by  the 
contracting  cellular  tissue;  pain;  local  malnutrition;  a  wide  variety 
of  reflex  nervous  disturbances ;  chronic  invalidism  :  all  these  are 
among  the  results  of  the  atrophic  process. 

In  contrast  with  the  chronic  atrophic  cellulitis  of  Freund  is  the 
so-called  cellulitis  of  Stapfev.  It  consists  of  oedematous  indurations 
in  the  abdominal  walls  and  in  the  floor  of  the  pelvis,  and  is  charac- 
terized by  pelvic  discomfort  and  inconstant,  transitory,  or  severe  pain. 
The  inflammation  is  of  very  mild  type,  with  slight  systemic  disturb- 
ance. The  transient  nature  of  the  disease  suggests  the  analogy  of 
urticaria  and  a  probable  angioneurotic  element  in  its  causation. 
Stapfer  declares  that  the  condition  is  common,  and  often  mistaken 
for  more  serious  affections.     The  author  never  has  observed  a  case. 

Symptoms  and  Diagnosis  of  Pelvic  Cellulitis. 

The  symptoms  are  nearly  identical  with  those  of  inflammation  of 
the  uterine  appendages.  The  reader  is  referred  therefore  to  that  sub- 
ject, especially  when  the  inflammation  is  secondary  to  salpingitis  or 
ovaritis,  or  is  situated  in  the  upper  part  of  the  broad  ligament  near 
the  tubes  and  ovaries.  When  the  disease  is  at  or  below  the  base  of 
the  broad  ligament  away  from  the  uterine  appendages  the  location  of 
pain  and  swelling  will  correspond  to  that  of  the  inflammation.  In 
acute  cellulitis  there  will  be  severe  radiating  pain,  in  many  cases  pain 
shooting  down  the  thighs,  high  fever,  chills,  great  local  sensitiveness, 
inability  to  walk  or  stand,  and  painful  urination  and  defecation. 
Acute  sym])toms  may  decrease,  and  when  suppuration  occurs  re- 
appear, modified  by  the  signs  of  pus-formation — that  is,  chills  and 
hectic  fever. 

The  symptoms  outlined  in  the  foregoing  paragraph  always  would 
suggest  a  tumor  in  the  pelvis  composed  of  products  of  inflammation, 
which,  if  present,  may  be  felt  as  a  hard  or  boggy  mass  usually  in  the 
lower  portion  of  one  of  the  broad  ligaments,  crowding  the  uterus  to 
the  opposite  side  of  the  pelvis  and  bulging  into  the  vagina.  Xot  infre- 
quently the  uterosacral  folds,  so-called  ligaments,  are  involved.  When 
these  folds  are  infiltrated,  the  inflammatory  mass  will  be  felt  posterior 
to  the  uterus  crowding  the  organ  to  the  anterior  part  of  the  pelvis. 
Later,  when  resolution  has  taken  place,  contraction  of  the  ligaments 
may  result  in  retroversion  or  anteflexion.  Post-uterine  cellulitis  is 
examined  best  by  rectal  touch.  If  the  inflammation  has  progressed 
to  the  third  stage — that  is,  to  the  formation  of  an  abscess — the  inflam- 
matory product,  wherever  situated,  usually  will  give  on  digital  exami- 
nation the  sensation  of  a  boggy,  fluctuating  mass. 


264    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

The  diagnosis  of  the  effusion  stage  of  pelvic  cellulitis  is  determined 
by  the  presence  in  the  pelvic  connective  tissue  of  an  inflammatory 
infiltrate  situated  at  some  point  adjacent  to  the  uterus  or  to  the  upper 
part  of  the  vagina.  This  infiltrate  may  be  observed  with  reference  to 
the  following  characteristics : 

1.  Location. 

2.  Form. 

3.  Relations. 

4.  Immobility. 

5.  Consistence. 

6.  Pain, 

1.  Location. — The  infiltrate  may  be  situated^ 

a.  On'  one  or  both  sides  of  the  uterus ;  if  unilateral,  it  will 
crowd  the  uterus  in  the  opposite  direction  and  depress  the 
lateral  fornix  of  the  vagina  on  the  aifected  side. 


FiGUEE  118. 


FiGUEE   119. 


Figure  118.— Fehlinsf's  three  divisions  of  the  pelvic  cavity:  A,  A,  peritoneal  division; 
B,  B,  subperitoneal  division ;  C,  C,  subcutaneous  division.  The  levator  ani  muscle  divides 
the  subperitoneal  from  the  subcutaneous  division. 

Figure  119.— Parametritis.  Exudate  in  left  subperitoneal  cavity,  crowding  corpus  uteri  to 
right.  Paracolpitis  in  right  subcutaneous  cavity,  crowding  cervix  uteri  and  vagina  to  left. 
This  latter  would  produce  a  peri-anal  abscess,  and  usually  would  be  followed  by  fistula  in  ano. 


b.  Between  the  folds  of  the  broad  ligaments  high  in  the  pelvis, 

with  a  tendency  to  extend  around  the  rectum. 

c.  In   the  post-cervical  connective  tissue,  blocking  up  the  cul- 

de-sac  of  Douglas  and  depressing  the  posterior  fornix  of 
the  vagina — parametritis  posterior. 

d.  In  the  connective  tissue  between  the  cervix  uteri  and  bladder 

— parametritis  anterior  ;  very  rare. 

e.  In  all  the  connective  tissue  around  the  uterus — circumuterine 

cellulitis. 

/.  In  the  subcutaneous  region,  as  shown  in  Fig.  119,  crowding 

the  cervix  uteri  and  vagina  to  the  opposite  side  and  having 

a  tendency  to  produce  a  peri-anal  abscess  with  resultant 

fistula  in  ano. 

2.  Form. — The  exudate,  sharply  circumscribed   or    diffuse,  will 

take  the  shape  of  the  resisting  structures  by  which  it  is  limited,  and 


PELVIC  CELLULITIS. 


265 


therefore  will  vary  in  form  from  a  round  to  oblong,  flat,  or  irregular 
mass. 

3.  Relations. — The  exudate  may  suri'ound  or  blend  with  neigh- 
boring parts,  such  as  the  rectum,  cervix  uteri,  vaginal  fornix,  and 
bladder. 

4.  Immobility. — The  exudate  usually  is  fixed,  the  degree  of  fixa- 
tion increasing  with  the  progress  of  the  disease. 

5.  Consistence. — The  exudate,  according  to  the  location  and 
resistance  of  surrounding  structures  and  to  the  composition  of  it,  may 
be  soft  and  elastic,  or  hard  and  less  elastic ;  it  may  contain  pus  or 
serum,  and  therefore  may  give  rise  to  fluctuation. 

6.  Pain. — In  most  cases  tenderness  and  pain  are  present. 


Differential  Diagnosis  of  Pelvic  Cellulitis.^ 

As  set  forth  in  the  accompanying  table,  pelvic  cellulitis  has  many 
characteristics  in  common  with  the  following  diseases  : 

Pelvic  peritonitis,  Perityphlitic  abscess,  appendicitis, 

Pyosalpinx,  Psoas  abscess, 

Pelvic  hsematocele,  Subserous  myoma. 

The  frequent  association  of  pelvic  cellulitis  with  pelvic  peritonitis 
and  with  salpingitis  may  render  the  differentiation  most  difficult.  It 
is  especially  difficult  when  cellulitis  and  peritonitis  coexist  in  puer- 
peral cases.  Early  efficient  examination  in  most  cases  of  cellulitis  is 
so  painful  as  to  be  impracticable  without  anaesthesia. 


Pelvic  'peritonitis. 

1.  Uterus  usually  surrounded  and  fixed  by 
an  infiltrate. 

2.  Blocking  up  of  the  vaginal  fornix  all 
around  uterus. 

3.  Mass  rather  high  in  pelvis. 

4.  Pain  severe  and  paroxysmal  in  acute 
stage. 

5.  Tendency  to  suppuration  not  marked. 

6.  Cervix  usually  fixed  in  median  line  with 
corpus  in  anteversion  or  anteflexion. 

7.  Frequently  results  in  general  peritonitis. 

8.  Anxious  facial  expression. 

9.  Both  legs  flexed  on  abdomen. 

10.  Nausea  and  vomiting  frequent. 

11.  Exudate  may  extend  to  upper  zones  of 
pelvis. 

12.  Pulse  rapid  and  weak. 
18.  Tongue  dry. 

Retro-uterine  peritonitis. 

1.  Mass  presents  round,  sharp  outline,  and 
may  involve  whole  posterior  s>irface  of  uterus. 

2.  Uterus  forced  forward. 

3.  Rectum  pressed  backward  in  median  line. 

4.  Adhesions  later  binding  posterior  surface 
of  uterus  and  fundus  uteri  to  rectum. 

Pyosalpinx. 

1.  Situated  to  one  or  both  sides  of  corpus 
uteri,  or  bound  behind  uterus  in  cul-de  sac 
of  Douglas. 

2.  Sharply  outlined,  sausage-shaped. 

3.  Limited  mobility  of  mass. 

4.  May  fluctuate  or  be  very  hard  and  resist- 
ing. 

5.  Usually  bilateral. 


Pelvic  cellulitis. 

1.  Tumor  usually  at  side  of  uterus. 

2.  Bulging  of  one  or  both   lateral  fornices, 
seldom  surround  uterus. 

3.  Mass  lower  in  pelvis  and  easily  palpated. 

4.  Pain  less  severe  and  more  continuous. 

5.  Great  tendency  to  suppuration. 

6.  Uterus  usually  displaced  laterally. 

7.  Not  frequently  so  complicated. 

8.  Facial  expression  not  characteristic. 

9.  One  leg  flexed,  seldom  both. 

10.  Less  frequent. 

11.  More  generally  confined  to  lower  zones. 

12.  Not  so  rapid ;  not  weak. 

13.  Tongue  may  be  moist. 

Eetro-uterine  celbdits. 

1.  Mass  flat,  diffuse,  and  usually  limited  by 
retro-uterine  fold  of  peritoneum. 

2.  Cervix  uteri  forced  forward. 

3.  Pressed  to  one  side  or  backward. 

4.  Adhesions  lower  and  nearer  cervix  uteri 


Lateral  cellnlitis. 

1.  Situated    low  and  blocking  vaginal   for- 
nices. 

2.  Usually  not  sharply  outlined,  but  flat  and 
diffuse. 

3.  Usually  fixation  of  mass. 

4.  Often  hard  and  resisting  before  suppura- 
tion and  fluctuation. 

5.  Usually  unilateral. 


«  These  tabular  statements  of  diflFerential  diagnosis  have  been  adapted  from   numerous 
works  on  gynecology. 


266     INFECTIONS,   INFLAMMATIONS,  AND  ALLIED  DISORDERS. 


Pelvic  hxinatucele. 

1.  History  of  tubal  pregnancy  with  sud- 
den and  alarming  signs  ot  internal  hemor- 
rhage. 

2.  No  chill,  fever  slight  or  absent.  May  be 
subnormal  temperature. 

3.  Rapid  development  of  tumor. 

4.  Tumor  soft  and  doughy  or  fluctuating; 
later  hard  and  may  be  elastic. 

5.  Usually  circumscribed  mass. 

6.  Exploratory  puncture — blood. 

PerityphUHc  abscess,  appendicitis. 

1.  Onset— constipation,  pain,  fever,  nausea, 
vomiting. 

2.  Tenderness  at  McBurney's  point. 

3.  Exudate  high— surrounds  caecum  ;  not  felt 
through  vagina. 

Psoas  abscess. 

1.  Usually  history  and  symptoms  of  tubercu- 
losis. 

2.  Spondylitis. 

3.  No  history  of  acute  inflammation. 

4.  Exploratory  puncture— typical  tubercular 
pus. 

Subserous  myoma. 

1.  Slow  development. 

2.  No  history  of  infection. 

3.  Contour  of  tumor — usually  round,  sharply 
circumscribed ;  tumor  intimately  connected 
with  the  uterus. 


Pelvic  cellulitis. 

1.  History  of  infection. 

2.  Chill  with  slight  or  high  temperature. 

3.  Slower  development. 

4.  Tumor  usually  hard  until  suppuration. 

5.  Usually  diifuse  mass. 

6.  Exploratory  puncture— negative,  serum,  or 
pus. 

Pelvic  cellulitis— right  side. 

1.  Onset— pain,  fever,  little  or  no  nausea  or 
vomiting. 

2.  Not  present. 

3.  Low  in  right  broad  ligament  or  post- 
nterine  connective  tissue,  easily  felt  through 
vagina. 

Pelvic  cellulitis. 

1.  Absent — history  of  non-tubular  infection. 

2.  Absent. 

3.  Usually  acute  at  first. 

4.  Ordinary  pus  or  serum. 

Pelvic  cellulitis. 

1.  Development  more  rapid. 

2.  History  of  infection. 

3.  More  diffuse,  not  so  intim.ately  connected 
with  the  uterus. 


Prognosis  of  Pelvic  Cellulitis. 

The  prognosis  in  the  acute  form,  uncomplicated  by  tubal  disease, 
is  good  usually.  The  inflammation  may  terminate  in  speedy  resolu- 
tion. If  abscesses  form,  there  may  be  rapid  and  complete  recovery 
after  evacuation  of  the  pus.  When  pus-tubes  coexist,  the  removal  of 
them  may  be  necessary.  The  chronic  atrophic  cellulitis  of  Freund  is 
obstinate  for  symptomatic  and  hopeless  for  histological  cure. 


Treatment  of  Pelvic  Cellulitis. 

Treatment  of  Acute  Cellulitis. — The  prophylactic,  palliative, 
abortive,  and  surgical  treatment  is  the  same  as  that  of  Acute  Metritis, 
Chapter  XIV.  When  the  disease  is  secondary  to  salpingitis,  the 
treatment  should  be  directed  to  the  uterine  appendages.  If  the  source 
of  the  acute  infection  has  been  a  wound  made  in  a  surgical  operation 
or  in  parturition,  the  exposed  surfaces  should  be  cauterized  thor- 
oughly. For  this  purpose,  it  may  be  necessary  to  remove  the  sutures 
from  a  recently  repaired  cervix  or  perineum.  Should  the  source  of 
infection  be  an  infected  endometrium,  sharp  curettage  of  the  endo- 
metrium may  be  considered.     See  Chapter  XIV. 

If  an  abscess  forms,  it  should  be  opened  and  drained  ;  the  tech- 
nique of  the  operation  is  the  same  as  that  described  in  the  following 
paragraph  for  opening  and  draining  a  ])elvic  abscess. 

Surgical  Treatment  of  Chronic  Cellulitis. — If  suppuration  has 
taken  place,  the  abscess  should  be  opened  promptly  and  drained.  In 
most  cases  the  opening  should  be  through  the  vagina  ;  but  if  the  pus 
points  toward  the  abdominal  wall,  it  may  sometimes  be  reached  and 
drained    by  an   abdominal  incision  direct  into  the  abscess    without 


PELVIC  CELLULITIS.  267 

opening  the  general  perituueiiin.  Under  no  circumstance  should  the 
incision  be  made  througli  the  rectum.  Persistence  of  suppuration 
after  drainage  indicates  i)robable  tubal  disease  and  may  require  re- 
moval of  the  uterine  appendages.  In  this  connection  the  reader  is 
referred  to  the  treatment  of  pelvic  suppuration  by  incision  and 
drainage — Chapter  XXIII. 

Non-surgical  Treatment  of  Chronic  Cellulitis. — AVhen  the 
a,cute  symptoms  subside,  absorption  may  be  promoted  by  the  hot 
water  vaginal  douche  as  described  in  Chapter  IV.,  by  the  internal 
use  of  calomel  in  doses  of  ^V  ^^  To  &^^^^  three  times  a  day  ;  by  saline 
laxatives,  sitz  baths,  and  hot  fomentations. 

The  treatment  of  chronic  non-suppurative  cellulitis — that  is,  the 
at7'02jhiG  vai'iety  of  Freund — is  discouraging.  The  estimated  value 
of  sea-bathing,  electricity,  glycerin  and  tannin  tamponade,  vaginal  and 
rectal  douclies,  and  painting  with  iodine,  varies  widely  with  different 
physicians.     The  author  has  not  found  such  measures  of  great  value. 


CHAPTER    XXI. 

INFLAMMATION    OF    THE    UTERINE    APPENDAGES-SAL- 
PINGITIS,   OVARITIS,   PELVIC  PERITONITIS. 

SALPINGITIS. 

Salpingitis  is  inflammation  of  the  Fallopian  tube. 

Normal  Anatomy. 

The  Fallopian  tubes  are  developed  bv  that  part  of  Miiller's  ducts 
above  the  round  ligaments.  The  jjart  below  the  round  ligaments, 
together  with  the  Wolffian  ducts,  converges  to  form  the  uterus  and 
vagina.  The  tubes  therefore  are  directly  continuous  with  the  uterus. 
Chapter  XXVII. 

The  mucous,  muscular,  and  peritoneal  layers  of  the  uterus  are 
directly  continuous  into  and  form  the  tubes.  By  analogy  of  uterine 
nomenclature  these  three  layers  of  the  tube  are  named  from  within 
outward,  as  follows  : 

1.  The  endosalpinx. 

2.  The  myosalpinx. 

3.  The  perisalpinx. 

The  tubes  extend  from  the  horns  of  the  uterus  outward  on  either 
side  and  follow  a  bending  course  along  the  upper  border  of  the  broad 
ligament  to  a  variable  length  of  from  three  to  five  inches.  They  are 
divided  into  three  parts  : 

The  isthmus. 

The  ampulla. 

Tlie  fimbriated  extremity. 
The  Isthmus — i.  e.,  the  constricted  portion  of  the  tube — starts  from 
the  endometrium  at  the  horn  of  the  uterus,  runs  through  the  uterine 
wall,  and  continues  outward  toward  the  lateral  wall  of  the  pelvis 
about  one  inch.  The  calibre  of  the  isthmus  at  the  uterine  junction, 
ostium  uterinum,  is  so  small  as  scarcely  to  admit  a  bristle.  This  con- 
stricted portion,  unless  dilated  by  disease,  would  prevent  an  intra- 
uterine injection  or  secretion  from  entering  the  abdominal  cavity.  It 
also  serves  to  protect  the  tube  against  infection  from  the  uterus  and 
the  uterus  against  infection  from  the  tube. 

The  Ampulla  is  the  expanded  portion  of  the  tube,  and  easily  admits 
the  uterine  probe.  It  runs  from  the  isthmus  backward  and  downward 
around  the  outer  border  of  the  ovary,  and  terminates  in  an  expanded, 
trumpet-shaped  part  called  the  infundibulum. 

The  Fimbriated  Extremity  at  the  abdominal  opening  is  really  the 
termination   of  the   ampulla.     It  is  made  up  of   irregularly  shaped 

268 


PLATE   Vir 


FIGURE   1. 


Cross-section  of  the  Normal  Fallopian  Tube  at  the  Uterine 

Ostium. 

M,   mucosa.      CMF,   circular  muscle   fibres.      LAIF,    longitudinal   muscle   fiVjres. 
SCT,  subperitoneal  connective  tissue.      lo  diameters. 


FIGURE  2. 


Cross-section  of  Fallopian  Tube  through  Abdominal  Ostium. 

Observe  the  high  mucous  folds  of  the  endosalpinx. 

The  walls  of  the   tube  in  both  figures   contain  numerous  bloodvessels  shown 
in  red.      lo  diameters. 


INFLAMMATION  OF  THE   UTERINE  APPENDAGES.  269 

processes,  all  freely  movable  except  one,  which  runs  along  the  tubo- 
ovarian  ligament  and  joins  the  ovary.  These  fimbriae  are  branches 
from  the  high  mucous  folds  of  the  endosalpinx. 

The  abdominal  openings  of  the  tubes  are  sometimes  multiple,  with 
more  than  one  fimbriated  extremity  for  a  single  tube. 

The  Endosalpinx,  or  mucous  lining,  continuous  with  that  of  the 
uterus,  is  made  of  loose  connective  tissue  covered  with  a  single  layer 
of  ciliated  columnar  epithelium.  The  cilia  always  are  directed  toward 
the  uterus,  and  probably  serve  to  propel  the  ovum  in  that  direction. 
The  mucosa  in  the  isthmus  is  relatively  smooth ;  in  the  ampulla  it 
rises  in  numerous  high  folds.  This  is  shown  abundantly  in  cross-sec- 
tion by  the  accompanying  plate.  The  presence  of  glands  in  the  Fal- 
lopian tube  has  been  denied.  Bland  Sutton,  after  an  extensive  com- 
parative study  of  the  tubes  of  the  lower  animals  and  of  woman, 
declares  that  the  plications  or  folds  of  the  tubal  mucous  membrane 
"are  disposed  on  the  same  principle  as  the  glands  in  the  uterus." 

The  probable  function  of  the  tubal  folds  is  to  provide  an  albumin- 
ous fluid  for  the  ovum  as  it  traverses  the  tube.  The  tube  participates 
only  in  slight  degree  if  at  all  in  menstruation.  As  shown  in  ectopic 
gestation  it  retains  some  power  to  develop  the  fertilized  ovum. 

The  Myosalpinx  is  made  of  two  muscular  layers,  internal  circular 
and  external  longitudinal.  These  layers  are  continuous  with  the  cor- 
responding layers  in  the  uterus.  It  is  not  known  whether  or  not  the 
tube  has  peristaltic  power. 

The  Perisalpinx,  or  peritoneal  investment  of  the  tube,  meets  the 
mucous  lining  at  the  abdominal  opening.  It  covers  about  four-fifths 
of  the  circumference  of  the  tube,  and,  converging  toward  the  broad 
ligament,  forms  a  narrow  mesosalpinx.  Between  the  layers  of  the 
mesosalpinx  is  an  abundance  of  loose  connective  tissue  through  which 
the  lymph-vessels  and  blood-vessels  and  nerves  directly  reach  the  tube. 

Classification  of  Salpingitis. 

The  following  varieties  and  phases  of  salpingitis  are  distinguished  : 

1.  Catarrhal  salpingitis — salpingitis  serosa. 

2.  Purulent  salpingitis — salpingitis  purulenta. 
Catarrhal  salpingitis  may  result  in  : 

Sactosalpinx  serosa — hydrosalpinx. 
Purulent  salpingitis  may  result  in  : 

Sactosalpinx  purulenta — pyosalpinx. 
If  sactosalpinx  is  complicated  by  hemorrhage  into  the  tube,  it  is 
called  sactosalpinx  hsemorrhagica  or  hsematosalpinx ;  this  is  more 
common  in  serous  than  in  purulent  infections.  Tubercular  salpingitis, 
an  especially  important  variety  of  purulent  infection,  will  be  described 
separately. 

Etiology  of  Salpingitis. 

The  causes  may  be  classified  into  : 

I.,  predisposing  causes — favoring  conditions. 
II.,  exciting  causes. 


270    IXFECTIOyS,    INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

I.  The  predisposing  causes  are  : 

1.  Abortion,  labor,  instrumentation,  and  manipulations. 

2.  Infections  in  neighboring  organs  which  may  reach  the  tubes 

by  extension.     Tubal  disease  is  rarely  primary. 

3.  Menstrual  congestion,  injudicious  exercise  at  the  beginning 

of  menstruation,  taking  cold  during  menstruation,  exces- 
sive coitus. 

4.  Acute  exanthemata. 

5.  Long  tortuous  tube. 

6.  Neoplasms. 

II.  The  exciting  causes  are  bacterial,  and  are  the  same  as  those 
set  forth  in  Chapter  XIX.,  on  Pelvic  Inflammation  in  General. 

Bacterial  studies  of  salpingitis  as  talndated  by  Gebhard,  from  the 
clinics  of  eight  surgeons,  gave  the  following  results : 

Gonococcus 86  cases. 

Streptococcus 32  "^ 

Pneumococcus 9 

Bacterium  coli  communis 7  " 

Uncertain 14 

Sterile J04  " 

Total 352  " 

Visceral  disorders  as  of  the  heart,  lungs,  liver,  and  kidneys ;  and 
systemic  diseases  as  syphilis,  rheumatism,  and  gout,  are  associated 
frequently  with  salpingitis. 

Pathology  of  Salpingitis. 

The  pathology  of  catarrhal  and  purulent  salpingitis  presents  many 
points  in  common.  To  some  extent,  therefore,  one  description  will 
answer  for  both. 

Xo  sharp  clinical  lines  of  demarcation  can  be  drawn  between  the 
inflammations  of  the  different  layers  of  the  tube. 

The  infection  usually  passes  to  the  tube  from  the  endometrium, 
catarrhal  endometritis  giving  rise  to  catarrhal,  salpingitis,  and  puru- 
lent endometritis  to  purulent  salpingitis.  Other  possible  routes  of 
infection  have  been  described  in  Chapters  X.  and  XIX.  Tubercu- 
lous salpingitis,  for  example,  usually  reaches  the  tube  from  above. 

Endosalpingitis,  whether  catarrhal  or  suppurative,  may  extend 
beyond  the  tube  in  three  different  ways  as  follows  : 

1.  If  the  abdominal  end  of  the  tube  remains  open,  the  secretion 
may  flow  out  and  infect  the  adjacent  peritoneum  and  the  epithelial 
covering  of  the  ovary,  producing  periovaritis,  or  if  there  be  at  the 
time  a  freshly  ruptured  Graafian  follicle,  the  infection  may  enter  the 
ovary  and  produce  ovaritis.  Adhesions  may  form  between  the  tube 
and  whatever  peritoneal  surface  is  in  contact  with  it.  The  ovary  also 
may  be  in  the  grasp  of  the  fimbriae,  and  so  glued  to  the  ampulla  as 
completely  to  close  the  tube. 

2.  The  infection  may  pass  through  the  walls  of  the  tube  by  way  of 
the  lymph-channels  and  produce  perisalpingitis — i.  e.,  inflammation  of 
the  peritoneal  covering  of  the  tube ;  thus  local  peritonitis  may  spread 
to  the  pelvic  or  even  to  the  general  peritoneum.     All  three  layers  of 


INFLAMMATION  OF  THE    UTERINE  APPENDAGES.  271 

the  tube,  mucous,  muscular,  and  serous,  together  with  all  the  connec- 
tive tissue  of  the  tube,  become  greatly  thickened,  hard,  and  convoluted, 
and  are  now  involved  in  a  diffuse  salpingitis.  Adhesions  usually  form 
between  the  serous  covering  and  adjacent  organs.  The  secretions  may 
be  clear  or  clouded,  catarrhal  or  purulent,  and,  unless  the  abdominal 
opening  has  been  closed  by  swelling  or  by  adhesions,  may  be  forced 
into  the  peritoneum. 

3.  The  infection  may  pass  through  the  mesosalpinx  into  the  loose 
connective  tissue  between  the  folds  of  the  broad  ligament,  producing 
perilymphangitis  and  periphlebitis — i.  e.,  the  cellular  tissue  around 
the  lymph-channels  and  veins  may  become  inflamed.  This  inflamma- 
tion is  pelvic  cellulitis.     Chapter  XX. 

The  second  and  third  modes  of  extension  are  more  likely  to  occur 
if  the  tube  has  become  distended  by  pathological  secretions,  a  com- 
mon result  of  plastic  occlusion  of  the  abdominal  end  or  of  mechanical 
closure  from  swelling  of  the  uterine  end.  Occlusion  from  swelling 
does  not  continue  if  recovery  takes  place  ;  that  from  adhesive  inflam- 
mation is  usually  permanent. 

The  acute  and  chronic  salpingitis  shade  off  one  to  the  other,  so 
that  the  difference  between  them  is  one  rather  of  degree  than  of  kind. 
Chapter  X. 

The  germs  which  produce  the  disease  are  demonstrable  in  acute 
salpingitis.  Chronic  accumulations  of  pus  in  the  tubes  are  usually 
sterile — i.  e.,  the  micro-organisms  have  disappeared  and  the  pus  is  no 
longer  infectious.  It  is  said  that  the  bacteria  die  from  the  accumula- 
tion of  their  own  products.  The  escape  of  such  sterile  pus  into  the 
pelvic  cavity  from  ruptured  tubes  during  operation,  or  from  any  other 
cause,  is  not  so  dangerous  as  it  was  supposed  to  be  when  pus  was  con- 
sidered always  infectious. 

Sactosalpinx. — When  both  ends  of  the  tube  are  closed  either  by 
swelling  or  by  adhesive  inflammation,  and  the  walls  become  distended 
with  the  accumulated  secretions,  the  disease,  as  indicated  under 
Classification,  is  called  sactosalpinx.  Three  varieties  are  distin- 
guished, as  follows  : 

Sactosalpinx  serosa — hydrosalpinx. 
Sactosalpinx  purulenta — pyosalpinx. 
Sactosalpinx  hsemorrhagica — hsematosalpinx. 

The  serous  accumulation  of  catarrhal  salpingitis  is  known  as  sacto- 
salpinx serosa,  or  hydrosalpinx.  A  purulent  accumulation  is  sacto- 
salpinx purulenta,  or  pyosalpinx.  An  accumulation  of  blood  in  the 
tube  is  hsematosalpinx,  or  sactosalpinx  haemorrliagica. 

Extensive  and  firm  adhesions  usually  take  place  between  pus-tubes 
and  the  adjacent  organs,  especially  the  ovaries.  Both  the  tube  and 
ovary  then  may  be  rolled  together,  universally  adherent  in  the  pos- 
terior fold  of  the  broad  ligament.  This  condition  is  more  common  in 
the  sup])urative  than  in  the  catarrhal  variety.  Tubo-ovarian  abscess 
or  purulent  tubo-ovarian  cyst  may  form  in  consequence  of  such  ad- 
hesions. 

The  orlor  of  the  pus  is  often  verv  ofiFensive,  and  if  the  tube  be 
adherent  to  the  rectum  may  be  fecal. 


272    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Figure  120. 


— T'''^"^.^ 

\ 

^^W" 

^-^ 

1 

Hydrosalpinx. 


Figure  121. 


/^,   ,.^ 

^ 

A 

i^^il 

1^ 

■  i             j 

^■.1* 

B^l  if, 

A|:  ^^ ' 

*'■■ 

1 

vH^H^^^^by  j^'^'^^^^^^^H^^^^i^^ 

1 

1 

^y^ 

r 

^ 

?, 

Pyosalpinx. 


Figure  122. 

^|H_,^ 

"^>-^ 

^"1 

h 

Kfll^H 

^^fll 

^^ 

p 

p 

Hsematosalpin:^, 


PLATE   VIJI 


FIGURE   1. 

^.-^ 

^-— :                     ^^^^ 

/ 

1 

/. 

\ 
1 

\ 

('^> 

' 

_ 

--^_- 

^T      ,         - 

\ 

i 

V 
\ 

/                             ^""^ 

^- 

--- 

Follicular  Hydrosalpinx  (Catarrhal  Salpingitis).     Cross-section 
Near  the  Middle  of  the  Tube. 

The  folds  of  the  swollen  mucosa  have  grown  together  so  that  the  deep  parts 
of  the  inflamed  mucosa  have  been  shed  off  partly  or  wholly  from  the  lumen  and 
have  formed  small  cysts,  a  frequent  result  of  catarrhal  salpingitis.  The  epithe- 
lium here  remains,  but  in  the  latter  stage  of  the  disease  it  may  be  destroyed. 
15  diameters. 

FIGURE  2. 


Same  as  Figure  i  Highly  magnified  Here  also  are  shown  a  number  of 
variously  shaped  cavities  The  high  mucous  folds  are  swollen  and  infiltrated 
with   the  round  cells  of  inflammation.      loo  diameters. 


INFLAMMATION  OF  THE   UTERINE  APPENDAGES.  273 

Pus-sacs  often  burst  into  adherent  organs — rectum,  bladder,  or 
intestine.  Unlike  cellulitis  abscess,  pyosalpinx  does  not  often  burst 
spontaneously  into  the  vagina.  The  relief  Avhich  comes  from  the 
rupture  of  a  pus-tube  into  an  adjacent  organ  is  apt  to  be  temporary, 
for  the  pus  usually  reaccumulates.  The  escape  of  fluid  from  a  hydro- 
salpinx or  pyosalpinx  into  the  uterus  is  called  salpingitis  profluens. 

Hydrosalpinx  in  one  tube  and  pyosalpinx  in  the  other  are  not  un- 
common. Separate  compartments,  formed  by  occlusion  of  a  tube  at 
different  points,  may  result  in  distention  of  these  compartments  with 
different  fluids ;  hence  there  may  be  in  the  same  tube  hydrosalpinx, 
pyosalpinx,  and  hsematosalpinx. 

The  distended  tube  often  has  the  form  of  a  pear,  the  narrow 
part  toward  the  isthmus  corresponding  to  the  stem  and  the  distended 
ampulla  to  the  wide  part  of  the  pear.  In  hydrosalpinx  the  fluid  is 
clear,  and  in  the  absence  of  adhesions  to  the  broad  ligament  the  sac 
often  is  felt  freely  movable  in  the  pouch  of  Douglas. 

Haematosalpinx  may  occur  as  the  result  of  hemorrhagic  salpin- 
gitis. The  sac-walls,  especially  if  the  hemorrhage  be  non-inflamma- 
tory, as  in  tubal  pregnancy,  are  very  thin  and  easily  ruptured.  The 
blood  may  not  or  may  be  mixed  with  tubal  secretions,  and  if  rupture 
does  not  occur,  may  be  absorbed.  Admixture  with  blood  may  take 
place  in  all  forms  of  inflammation,  but  an  inflamed  tube  must  contain 
blood  in  considerable  quantities  in  order  to  be  designated  by  the  term 
hemorrhagic  salpingitis  or  hcematosalpinx.  The  latter,  however,  may 
occur  without  inflammation.  Usually  the  blood  of  hsematosalpinx 
due  to  tubal  pregnancy  is  clotted  ;  that  due  to  salpingitis  is  often 
quite  thick,  and  may  resemble  tar,  but  is  not  usually  clotted. 

Tubo-ovarian  Cyst  and  Tubo-ovarian  Abscess  may  form  as  follows  : 
The  adhesion  of  a  sactosalpinx  to  an  ovary  may  be  followed  by  the 
bursting  of  a  small  ovarian  cyst  or  a  corpus  luteum  into  the  tube  and 
the  establishment  of  a  permanent  communication  between  the  two. 
During  the  growth  of  the  tubal  sac,  which  is  now  part  of  a  tubo- 
ovarian  cyst,  the  ovarian  cyst  is  subject  to  the  same  pressure  as  the 
walls  of  the  tube ;  hence  the  ovarian  structure  becomes  flattened  so 
as  to  form  a  thin  wall  for  the  ovarian  portion  of  the  composite  cyst, 
and  thus  the  characteristic  structure  of  the  ovary  is  lost.  This  is  not 
to  be  confounded  with  ovarian  hydrocele.  Tubo-ovarian  cyst  may 
occur  in  connection  with  hydrosalpinx  or  pyosalpinx.  If  the  sacto- 
salpinx communicates  with  an  ovarian  abscess,  the  condition  is  called 
tubo-ovarian  abscess.     Figure  203. 

Comparative  Pathology  of  Catarrhal  and  Purulent  Salpin- 
gitis.— 


Catarrhal  salpingitis. 

1.  Infection  by  extension  from  catarrhal  en- 
dometritis. 

2.  Essentially  confined  to  mucosa— endosal- 
pingitis.  Walls  of  tube  in  acute  stage  slightly 
thickened ;  in  chronic  stage,  more  thickened. 
Complicating  peritonitis  not  common. 

3.  After  acute  stage,  little  or  no  pain  or  ten- 
derness. 

18 


Purulent  salpingitis. 

1.  Infection  usually  by  extension  from  puru- 
lent endometritis  ;  may  be  by  extension  from 
the  peritoneum,  as  in  tubercular  salpingitis. 

2.  Apt  to  extend  and  become  diffuse,  involv- 
ing all  layers  of  tube.  Walls  of  tube  very  much 
thickened  and  infiltrated  with  round  cells. 
Peritonitis  common  as  a  complication. 

3.  Pain  and  tenderness  pronounced. 


274    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED   DISORDERS. 


Catarrhal  sal])ingitis. 

4.  Tubal  adhesions  absent  or  less  pronounced. 
Mobility  and  elasticity.  Fluctuation  through 
thin  walls. 


5.  Sactosalpinx  will  be  hydrosalpinx— i.  e., 
tube  distended  with  serum ;  sometimes  ha;ma- 
tosalpinx.  j 

6.  Abdominal  end  of  tube  usually  closed  by  I 
adhesions  of  fimbriae ;  uterine  end  of  tube  less  j 
often  closed. 

7.  Sactosalpinx  may  be  due  to  occlusion  of  : 
tube  either  from  swelling  of  mucosa  or  adhe- 
sive inflammation:  if  the  former,  tube  may 
periodically  discharge  contents  into  uterus  or 
peritoneum,  giving  rise  to  colicky  pains— %- 
drops  lubss  profluens,  salpingitis  profluens. 

8.  Folds  of  mucosa  pressed  together  by  fluid 
contents ;  epithelium  disappears  by  pressure 
and  folds  grow  together ;  deeper  parts  of  in- 
flamed mucosa  may  be  partly  or  wholly  shut 
off  from  lumen  and  form  small  cysts— sa/pin- 
gitis  pseudofullicularis. 


9.  Mucous  folds  may  atrophy,  become  atten- 
uated, and  floating  in  the  fluid  have  a  wavy 
appearance  described  by  Sawinoflf  under  the 
name  salpingitis  vegetans.  Lumen  composed  of 
one  cavity. 

10.  Tube  thinned  and  translucent  in  propor- 
tion to  distention;  walls  atrophy:  fimbriae 
gradually  lost.  Tube  moderately  convoluted. 
Size  not  usually  larger  than  the  finger ;  shape  regu- 
lar, spindle,  round,  elongated,  or  convoluted. 

11.  Tube  rarely  ruptures  into  bowel,  vagina, 
bladder,  or  peritoneum. 


Pundent  salpingitis. 

4.  Adhesions  usually  extensive  to  cul-de-sae 
of  Douglas,  walls  of  uterus,  broad  ligaments, 
or  posterior  segment  of  pelvic  floor;  tube  im- 
mobile and  inelastic.  Fluctuation  masked  by 
thickness  of  tubal  walls. 

5.  Sacto.salpinx  will  be  pyosalpinx — i.e.,  tube 
distended  with  pus ;  pus  may  contain  blood. 

6.  Both  ends  of  tube  closed  by  adhesive  in- 
flammation. 

7.  Tube  usually  occluded  by  permanent  in- 
flammatory adhesions ;  hence,  salpingitis  pro- 
fluens less  frequent,  although  tube  may  rupture 
at  times  and  discharge  contents.  Purulent 
salpingitis  profluens  is  more  dangerous  than 
serous  salpingitis  profluens. 

8.  Folds  of  mucosa  may  be  adherent  or  oblit- 
erated ;  lumen  may  be  divided  partially  or 
wholly  into  spaces  by  constrictions  or  adhe- 
sions; these  spaces  may  be  distended  by  dif- 
ferent fluids  ;  hence  the  possibility  of  pyosal- 
pinx, hydrosalpinx,  and  hsematosalpinx  in  one 
tube  with  lumen  composed  of  several  cavities. 
Very  much  thickened  walls  of  tube  may  con- 
tain small  abscesses  usually  formed  between 
adherent  folds  of  mucosa. 

9.  Salpingitis  vegetans  never  occurs. 


10.  Tube  more  and  more  thickened  (irregular 
thickening)  in  proportion  to  distention,  much 
convoluted  and  nodular  ;  size  may  equal  that  of 
a  child's  head;  shape  most  irregular. 

11.  Such  rupture  and  discharge  not  common. 


Symptoms  of  Salpingitis. 

There  are  no  pathognomonic  signs  of  salpingitis.  Ovaritis  and 
pelvic  peritonitis  usually  are  related  so  closely  to  salpingitis  that  the 
symptoms  and  diagnosis  of  ovarian  and  peritoneal  infections  are  in- 
cluded largely  in  those  of  salpingitis.  Inflammation  of  the  tubes  and 
ovaries,  taken  as  a  whole,  is  designated  sometimes  as  adnexal  inflam- 
mation, or  inflammation  of  the  uterine  appendages. 

Pain. — The  symptoms  of  inflammation  of  the  uterine  appendages 
vary  with  the  extent,  virulence,  acuteness,  complications,  and  mechan- 
ical conditions  of  the  disease.  Usually  the  tubes  are  less  sensitive  to 
pain  than  the  ovaries ;  the  pain  of  salpingitis  is  increased  therefore 
when  the  disease  includes  peritonitis  and  ovaritis.  The  milder  catar- 
rhal inflammations,  even  though  acute,  may  cause  symptoms  so  slight 
as  scarcely  to  fix  the  patient's  attention  upon  the  diseased  part ;  they 
may  even  run  their  course  and  disappear,  leaving  no  trace  except  per- 
haps greater  liability  to  future  infection.  Such  unrecognized  mild 
congestive  and  catarrhal  attacks  of  salpingitis  are  probably  more  fre- 
quent than  generally  is  supposed. 

Local  pain  or  discomfort  in  the  affected  part  does  not  always  cor- 
respond to  the  seriousness  of  the  infection.  There  may  be  only  a  dull 
aching  or  a  sensation  of  burning  not  sufficient  to  impress  the  patient 
seriously  unless  aggravated  by  local  pressure,  by  vaginal  examination, 
by  exertion,  or  by  defecation,  and  yet  the  tube  may  be  distended 
ready  to  burst  into  the  peritoneal  cavity. 


PLATE    IX 


V 


arioso   ^  a  a   "     •'■ 


A 


;-^^-"-;^;^ 


P«RKER 


.J^^.'^^ 


A.  Diffuse  Hemorrhagic  Salpingitis.  Section  between  the  middle  and  outer 
third  of  the  tube.  The  high  mucous  folds  and  the  walls  of  the  tube  are  much 
swollen  and  congested. 

B.  Section  from  the  wall  of  the  tube  A. 

C.  Section  from  the  mucous  folds  of  the  tube  A.  Sections  A  and  B  both 
show  congested  thickening,  hemorrhagic  areas  and  infiltration  with  many  small 
round  cells  of  inflammation. 

A  magnified  lo  diameters.  B  magnified  loo  diameters.  C  magnified  30 
diameters. 


INFLAMMATION  OF  THE   UTERINE  APPENDAGES.  275 

In  a  small  minority  of  cases  salpingitis  is  characterized  from  the 
beginning  of  the  attack  by  very  acute  colicky  pains  in  the  region  of 
the  tubes,  with  intervals  of  comparative  comfort.  This  symptom, 
from  its  frequency  in  prostitutes,  has  been  called  colica  scortorum  ;  it 
has  been  attributed  to  salpingitis  profluens,  to  spasmodic  contractions 
of  the  muscular  wall  of  the  tube  or  uterus,  to  peritoneal  irritation,  to 
leakage  of  tubal  secretion,  and  to  occasional  rupture  of  the  walls  of 
the  tube,  but  these  explanations  are  unsatisfactory. 

Menstrual  Disturbances. — During  the  monthly  period  the  patho- 
logical congestion  is  supplemented  by  that  of  menstruation ;  hence 
the  pains  are  increased  and  dysmenorrhoea  is  the  rule.  Increased 
nKuistrual  flow,  even  to  the  extent  of  menorrhagia,  is  common. 
Amenorrhoea  or  scanty  menstruation  seldom  is  observed,  and  when 
present  points  to  possible  tuberculosis. 

Mechanical  Disturbances. — Greatly  dilated  and  swollen  tubes, 
especially  when  associated  with  local  peritonitis,  always  produce 
mechanical  disturbances.  This  is  more  marked  when  the  swelling 
has  been  rapid.  The  more  gradual  the  swelling  and  the  more  oppor- 
tunity the  parts  have  to  adapt  themselves  to  the  new  conditions,  the 
less  the  pain.  The  mechanical  symptoms  are  variable  and  numerous. 
They  include  painful  urination  and  difficulty  and  pain  on  walking 
and  standing. 

Comparative  Symptoms  of  Catarrhal  and  Purulent  Salpin- 
gitis.— 


Catarrhal  salpingitis. 

1.  Fever  present  in  acute  stage  and  usually 
absent  in  chronic  stage. 

2.  Pain  in  region  of  tube  variable  in  acute 
stage ;  usually  absent  or  almost  absent  in 
chronic  stage. 


3.  Salpingitis  profluens  not  uncommon. 


Purulent  salpingitis. 

1.  Fever  high  in  acute  stage.  Usually  slight 
evening  temperature  in  chronic  stage.  If  pus 
becomes  sterile,  temperature  may  be  normal. 

2.  Pain  and  systemic  disturbance  (anxious 
facies,  nausea,  depression)  more  pronounced 
in  acute  stage.  Pain  and  general  malnutrition 
usually  present  in  chronic  stage.  Symjitoms 
partly  due  to  extension  of  infection  to  neigh- 
boring organs,  producing  ovaritis,  pelvic  peri- 
tonitis, and  cellulitis. 

2.  Salpingitis  profluens  uncommon. 


Diagnosis  of  Salpingitis — Sactosalpinx. 

The  symptoms  outlined  in  the  foregoing  paragraphs  point  to  the 
probability  of  inflammation  around  the  uterus.  Indeed,  it  is  usually 
easy  to  recognize  the  presence  of  acute  ])elvic  inflammation,  especially 
when  inflamed  organs  are  crowded  with  products  of  inflammation. 
Physical  examination,  however  necessary  to  verify  the  diagnosis, 
will  frequently  not  only  fail  to  establish  sharp  diagnostic  lines 
between  inflammation  of  the  different  pelvic  organs,  but  also  between 
pelvic  inflammation  and  other  morbid  conditions,  such  as  neoplasms, 
with  which  an  inflammatory  mass  may  be  confused.  The  subjective 
symptoms  in  the  milder  cases  may  be  overlooked.  Indeed,  the  exist- 
ence even  of  pyosalpinx  sometimes  is  unrecognized  imtil  rupture  of 
the  tube  and  escape  of  pus  have  set  up  dangerous  peritonitis.  -The 
presence  of  nndometritis  even  should  place  one  on  guard  against  possi- 
ble salpingitis. 


276    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

In  order  to  avoid  the  accidental  rupture  of  a  pus-tube,  or  other 
abscess- wall,  care  in  the  palpation  of  uterine  appendages  is  enjoined. 

There  is  usually  a  recent  or  remote  antecedent  background  of  acute 
or  chronic  infection  in  some  neighboring  organ  ;  the  diagnosis  there- 
fore should  include  both  the  inflamed  appendages  and  the  antecedent 
causative  inflammation,  usually  endometritis,  but  sometimes  vaginitis, 
vulvitis,  cystitis,  proctitis,  or  appendicitis. 

Among  the  subjective  symptoms  will  be  dull,  often  burning,  con- 
stant, remittent,  or  intermittent  pain  and  local  tenderness.  The 
colicky  pains  about  the  tubes,  already  mentioned  under  symptoms, 
are  strongly  diagnostic.  Occasional  exacerbations  of  local  peritonitis 
from  leakage  of  the  tube  or  from  other  sources  are  characteristic  of 
adnexal  inflammation.  In  order  to  establish  the  diagnosis  the  symp- 
toms already  outlined  must  be  supplemented  by  physical  examination. 

Physical  Examination  is  by  external  palpation  and  conjoined  manip- 
ulation. The  former  is  usually  inadequate.  The  latter,  which  in- 
cludes external  palpation,  is  made  with  the  left  index-finger  in  the 
vagina  and  the  right  hand  over  the  hypogastrium  ;  or,  as  set  forth  in 
Chapter  III.,  with  the  left  index-finger  in  the  rectum,  the  thumb  in 
the  vagina,  and  the  right  hand  over  the  hypogastrium.  Light,  con- 
joined palpation  will  show  an  irregular  elongated  swelling  on  one  or 
both  sides  of  the  uterus,  frequently  extending  into  the  pouch  of 
Douglas,  or  even  sometimes  in  front  of  the  uterus.  It  is  often  im- 
possible to  make  out  the  component  parts  of  such  a  mass.  They  will, 
however,  usually  include  the  inflamed  tube  or  tubes  together,  in  vary- 
ing degree,  with  diseased  ovaries,  peritoneum,  intestine,  omentum, 
bladder,  and  uterus.  These  structures  may  be  matted  together  in  an 
irregular,  indefinite  tumor.  The  one  nearly  constant  factor  in  such 
a  mass  is  sactosalpinx. 

The  Diagnosis  of  Sactosalpinx  depends  upon  the  finding  of  a  tumor 
connected  with  the  uterus,  sausage-shaped  or  retort-shaped,  and  tender 
on  pressure.  Gonorrhoeal,  puerperal,  and  tubercular  are  the  three 
most  frequent  and  significant  forms  of  infection ;  it  is  therefore 
important  to  distinguish  between  them. 

Gonorrhoeal  sactosalpinx  will  he  y^ecognized  by : 
a.  History  of  suspicious  exposure. 

6.  Presence  of  gonorrhoeal  infection  in  uterus,  vagina,  or  vulva. 
c.  Bilateral  infection  ;  not  invariable. 
Tubercular  Salpingitis. — The  disease  is  generally  secondary  to 
tuberculosis  in  other  organs,  and  is  of  frequent  occurrence.  Whit- 
ridge  Williams  found  it  in  7.7  per  cent,  of  91  cases  of  removal  of  the 
uterine  appendages.  It  very  rarely  occurs  from  direct  infection  by 
coitus  or  other  media.  It  has  been  observed  as  early  as  the  fifth  year 
of  life,  and  is  the  most  frequent  form  of  salpingitis  found  in  virgins. 
It  usually  attacks  both  tubes  and  extends  to  the  surrounding  parts. 
Tubercular  pelvic  disease  is  characterized  by  mild  pyrexia,  weakness, 
often  splenic  enlargement,  and  thickening  of  the  subperitoneal  tissues. 
The- tendency  of  the  disease  is  toward  atresia  of  the  tube  and  the 
formation  of  pyosalpinx. 

Tubercular  salpingitis  may  be  acute  or  chronic.     The  abdominal 


INFLAMMATION  OF  THE  UTERINE  APPENDAGES. 


277 


end  of  the  tube  is  in  general  open  in  the  acute  and  closed  in  the 
chronic  cases ;  the  contents  of  the  closed  tube  are  serous,  purulent, 
or  caseous.  The  mucosa  in  acute  cases  may  contain  many  small 
tubercular  nodules.  In  these  nodules  are  found  few  giant  cells  and 
many  tubercle  bacilli.  Chronic  tubercular  sactosalpinx  is  often  a 
large  sac  containing  fluid  or  caseous  pus.  The  mucosa  is  destroyed, 
and  the  sac  is  lined  with  granular  tissue  which  contains  numerous 
giant  and  epithelioid  cells.  The  tubercle  bacillus  in  this  tissue  is 
often  impossible  to  find.  The  perisalpinx  presents  the  same  micro- 
scopical appearances  as  the  mucosa — that  is,  there  are  numerous  giant 
cells  and  few  if  any  tubercle  bacilli.  Chronic  fibroid  tuberculosis  of 
the  tubes  is  a  peculiar  form  described  by  Williams.  In  this  variety 
the  formation  of  connective  tissue  is  the  final  stage  of  the  tubercular 
infection.  The  contracting  fibrous  tissue  around  the  tubercular 
nodules  crushes  out  the  miliary  tubercles  and  prevents  spread  of 
the  disease. 

Figure  123. 


Tubercular  Fallopian  tube. 


Diagnosis  of  Tubercular  from  other  Forms  of  Salpingitis. — On  account 
of  the  similarity  of  symptoms  and  physical  signs  the  diagnosis  may 
be  very  difficult.  In  comparison  with  the  other  forms,  chronic  tuber- 
cular infection  is  more  apt  to  show  an  evening  rise  in  temperature  of 
about  one  degree,  and  a  marked  increase  in  the  frequency  of  the  pulse. 
Pain  and  menstrual  disturbances  are  not  particularly  diagnostic. 
Ascites  occurs  in  a  small  minority  of  cases  and  is  diagnostic.  The 
physical  signs  are  substantially  the  same  as  in  other  forms  of  sal- 
pingitis.    The  chief  diagnostic  points  are  : 

a.  Tuberculosis  in  other  organs  with  symptoms  intensified ; 
frequent. 

6.  Tuberculosis  in  husband. 

c.   Family  history  of  tuberculosis. 


278    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

d.  Salpingitis  in  virgins  ;  tubercular  in  90  per  cent,  of  all  cases. 

e.  Presence  of  tubercle  bacilli  in  leucorrhoea. 

/.    Scanty  menstruation  or  amenorrhoea  ;  not  uncommon. 

g.  Ascites ;  not  uncommon. 

h.  Palpation  of  tubercular  nodules  sometimes  possible. 

The  Distinction  of  One  Form  of  Bacterial  Infection  from  Another 
must  depend  upon  the  examination  of  the  secretions  for  bacteria. 
Such  an  examination  is  always  desirable,  but  sometimes  impracticable. 
The  vulvovaginal  and  uterine  secretions  in  the  acute  stage  not  infre- 
quently contain  the  causative  germs.  Pus  long  confined  in  the  tube 
is  apt  to  become  sterile.  This  explains  the  freedom  from  infection  so 
often  observed  after  a  pus-tube  has  ruptured  within  the  peritoneal 
cavity  during  an  operation.  The  inflammation  may  continue  long 
after  the  original  germs  have  disappeared,  or  at  least  after  their  pres- 
ence can  no  longer  be  demonstrated.  The  tuberculin  test  may  serve 
to  clear  the  diagnosis  of  early  primary  tubercular  salpingitis. 

The  differentiation  of  the  various  adnexal  inflammations  from  one 
another,  especially  in  the  acute  stage,  is  often  difficult.  Ovaritis, 
usually  a  consequence,  sometimes  a  cause  of  salpingitis,  is  not  easily 
distinguished  from  it  when  the  two  organs  are  fused  together  by 
adhesions,  and  when  the  tube  is  distended  with  fluid  the  difficulty  is 
increased. 

Differential  Diag-nosis  of  Salpingitis — Sactosalpinx. — Sacto- 
salpinx  closely  resembles  many  other  conditions,  some  of  them  inflam- 
matory and  some  non-inflammatory ;  it  usually  may  be  distinguished 
from  inflammatory  growth  by  the  location,  and  from  non-inflammatory 
developments  by  the  history  of  inflammation. 

The  principal  affections  for  which  sactosalpinx  may  be  mistaken 
are  set  forth  in  the  following  parallel  columns  : 


Sactosalpinx. 

1.  Commonly  bilateral. 

2.  Tube  oblong  and  tortuous. 

3.  Commonly  adherent. 

4.  Ovary  often  palpated  and  distinguished. 

5.  Usually  not  larger  than  fist. 

6.  May  be  leucocytosis. 

Sactosalpinx. 

1.  Common. 

2.  Usually  bilateral. 

3.  Sensitive  to  pressure. 

4.  Usually  fixed. 

5.  Elastic  or  fluctuating. 

6.  Result  of  infection. 

Sactosalpinx. 

1.  Usually    sharply    circumscribed  and    of 

rounded  contour. 

2.  Commonly  bilateral. 

3.  Elastic  and  fluctuating.  Not  a  reliable  sign. 

4.  Position  relative  to  viterus  :   mass   usually 

higlier  iu  pelvis  near  fundus  uteri ;  not 
connected  with  cervix.  Vaginal  vaul'., 
not  depressed. 


Q/sfic  ovarian  tumor 

1.  Commonly  unilateral. 

2.  Spheroidal  or  spherical. 

3.  Less  commonly  adherent. 

4.  Tumor  is  diseased  ovary 

5.  May  grow  to  enormous  size. 

6.  No  leucocytosis. 

Solid  tumor  of  tiibe. 

1.  Rare. 

2.  Usually  unilateral. 

3.  Not  sensitive. 

4.  Usually  free  and  mobile. 

5.  Firm  consistence. 

6.  Cause  unknown. 

Pelvic  cellulitis. 

1.  Not  sharply  circumscribed;    maybe  flat- 

tened. 

2.  Commonly  unilateral. 

3.  Less  elastic  and  fluctuating.    Not  reliable. 

4.  Position  relative  to  uterus,  usually  lower 

in  pelvis,  often  closely  connected  with 
uterus.  Vagina],  vault  commonly  de- 
pressed. 


INFLAMMATION  OF  THE   UTERINE  APPENDAGES. 


279 


Sactosalpinx. 

1.  Mass  usually  elastic ;  may  fluctuate. 

2.  Adhesions  common. 

3.  Hensitive  to  pressure. 

4.  Uterine  end  of  tube  enlarged. 

5.  History  of  infection. 


Sactosalpinx  (right  side). 
1.  Tumor  felt  by  vaginal  touch. 


2.  After  acute   stage,  size  of  tumor  may  not 

materially  diminish. 

3.  Recurrence  less    dangerous  and  less  fre- 

quent. 

4.  More  frequently  of  gouorrhceal  or  tuber- 

cular origin. 


Tubal  pregnancy. 

1.  Consistence  often  quite  firm. 

2.  Less  common. 

3.  Not  sensitive. 

4.  Commonly    normal     except     interstitial 

tubal  pregnancy. 

5.  History  of  pregnancy. 

a.  Amenorrhoea. 

h.  Increase  in  size  of  uterus. 

c.  Enlargement  of  breasts. 

d.  Morning  sickness. 

e.  Rupture  of  tube  with  great  pain,  col- 

lapse (pelvic  hjematocele),  uterine 
hemorrhage,  and  discharge  of  de- 
cidual membrane. 

Appendicitis. 

1.  Tumor  not  usually  within  reach  of  vaginal 

touch,  but  felt  or  is  tender  to  pressure  on 
external  palpation  in  region  of  Mc- 
Burney's  point. 

2.  After  acute  stage,  tumor  apt  to  disappear. 

3.  Recurence    more    dangerous     and  more 

frequent, 

4.  More  frequently  due  to  colon  bacillus,  less 

frequently  of  tubercular  origin  ;  never 
gouorrhceal  unless  by  extension  from 
tube. 


Among  the  other  conditions  which  may  in  some  respects  resemble 
sactosalpinx  are  these : 

Displaced  uterus,  Displaced  abdominal  organs, 

Tumors  of  the  sacrum  and  ilium,     Adherent  intestine, 
Fecal  accumulations,  Intestinal  tumors. 

Study  of  the  diagnosis  of  lateral  and  backward  versions  and  flexions 
of  the  uterus,  in  Chapter  XLVI.,  and  of  Uterine  Myomata,  in  Chap- 
ter XXYI.,  will  enable  the  student  to  distinguish  these  conditions 
from  sactosalpinx. 

Tumors  of  the  sacrum  and  ilium  are  distinguished  by  their  location, 
hardness,  immobility,  and  intimate  relations  with  the  bony  pelvis. 

Fecal  accumulations  may  be  recognized  by  palpation,  and  may  be 
removed  by  cathartics. 

Displaced  kidney,  spleen,  and  other  abdominal  viscera,  intestinal 
adhesions  and  intestinal  tumors,  may  usually  be  recognized  by  their 
remoteness  from  the  uterus,  or  by  the  fact  that  they  may  on  manipu- 
lation be  separated  from  that  organ.  The  author  has  had  a  case  of 
tumor  of  the  sigmoid  flexure  adherent  to  the  cul-de-sac  of  Douglas, 
and  on  conjoined  examination  having  all  the  appearance  of  a  larger 
sactosalpinx.  Diagnosis  was  made  only  after  enucleation  of  the  mass 
from  its  surroundings. 

Anaesthesia  is  often  necessary  in  order  to  make  a  satisfactory  diag- 
nosis and  diiferential  diagnosis  of  adnexal  inflammation,  and  should  be 
used  in  cases  of  doubt.  Relaxation  of  the  abdominal  muscles  under 
anaesthesia  permits  more  efficient  palpation  with  the  minimum  force, 
and  consequently  with  the  minimum  risk.  Many  unnecessary  la]ia- 
rotomies  would  doubtless  be  avoided  by  more  careful  diagnosis  under 
anaesthesia.  The  more  or  less  distended  bladder  or  bowel  often  has 
been  mistaken  for  a  pathological  collection  of  serum,  blood,  or  pus  ; 
hence  evacuation  of  the  bladder  and  rectum  is  a  prerequisite  to 
examination 


280    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Exploratory  Incision. — In  serious  pelvic  disease  the  diagnosis,  if 
not  possible  or  satisfactory  by  the  above  means,  may  be  made  by 
exploratory  vaginal  or  abdominal  section.  The  incision  may  become 
the  first  step  of  a  radical  operation  or,  if  the  operation  prove  unneces- 
sary, may  be  closed  safely.  It  is  a  good  rule  always  to  begin  a  peri- 
toneal operation  as  a  diagnostic  exploratory  incision.  As  Mr.  Tait 
wisely  remarked,  "  It  is  better  to  turn  an  exploratory  incision  into  an 
operation  then  it  is  to  turn  an  operation  into  an  exploratory  incision." 
The  late  Charles  T.  Parkes,  when  questioned  by  a  bystander  at  the 
beginning  of  an  abdominal  section,  replied,  "  I  don't  know  what  it  is, 
and  I  am  tired  of  guessing." 

Prognosis  of  Salpingitis. 

In  acute  adnexal  inflammation  the  prognosis  varies  with  the  nature 
of  the  infection  and  with  the  extent  of  the  disease.  If  the  tube  rupt- 
ures and  discharges  pus  into  the  peritoneum,  a  fatal  peritonitis  may 
follow.  If  the  infection  is  confined  to  the  tube,  the  prognosis  is 
usually  favorable,  but  the  removal  of  the  appendages  may  be  neces- 
sary for  permanent  recovery. 

Simple  catarrhal  salpingitis  and  mild  ovaritis  may  run  their  courses, 
perchance  unrecognized,  to  recovery.  They  may  even  leave  no  trace 
behind  except  an  increased  liability  to  further  inflammation.  The 
more  chronic  the  disease  the  less  favorable  the  outlook  for  expectant 
treatment.  The  rule  that  sactosalpinx,  especially  the  purulent 
variety,  rarely  recovers  Avithout  operative  interference,  is  not  without 
exception,  for  pus  cavities  may  rupture  spontaneously  and  discharge 
their  contents  through  the  bowel,  uterus,  bladder,  vagina,  or  cutaneous 
surface,  and  recovery  may  follow ;  but  such  a  possibility  does  not 
oifer  substantial  hope  of  relief.  In  fact,  even  when  such  rupture  and 
discharge  are  followed  by  relief  the  result  is  usually  only  temporary, 
and  the  patient  may  succumb  to  repeated  infection. 

Serous  sactosalpinx,  although  little  dangerous  to  life,  may,  by  per- 
manent closure  of  the  tubes,  cause  loss  of  function  and,  if  the  disease 
is  bilateral,  sterility.  Purulent  sactosalpinx  is  a  constant  danger  even 
to  life.  The  gonococcus  is  less  perilous  to  life,  though  probably  more 
dangerous  to  health  than  the  streptococcus.  The  streptococcus  is  apt 
to  destroy  life,  while  the  gonococcus  in  a  physiological  sense  destroys 
the  reproductive  organs  and  makes  a  chronic  invalid. 

The  danger  of  operation  varies  with  the  extent  of  the  disease,  the 
kind  of  operation,  the  operator,  and  the  nature  of  the  causal  bacteria. 
The  mortality  shown  by  some  statistics  is  enormous  ;  other  reports  give 
almost  100  per  cent,  of  recoveries.  The  removal  of  a  gonococcus 
sactosalpinx  is  less  dangerous  than  that  of  a  streptococcus  sactosal- 
pinx. This  is  especially  true  if  the  sac  ruptures  into  the  peritoneum. 
The  more  chronic  the  disease,  the  less  the  danger  of  the  operation. 

One  hundred  and  forty-four  cases  of  removal  of  sterile  pus  tubes 
show  a  mortality  of  2.8  per  cent.^  The  avarage  mortality,  among  the 
best  operators,  following  removal  of  pus  tubes  is  from  2  to  3  per  cent. 

1  Martin.    Die  Krankheiten  der  Eileiter. 


INFLAMMATION  OF  THE  UTERINE  APPENDAGES.  281 

Operations  in  sixteen  cases  of  gonococcus  sactosalpinx  in  which 
the  sac  was  removed  intact  show  a  mortality  of  6.2  per  cent. ;  in 
seventeen  cases  in  which  it  burst  during  removal  the  mortality  rises 
to  11.7  per  cent.  In  another  similar  series  the  mortality  was  8.35 
per  cent,  and  11.1  per  cent.,  respectively.^ 

It  is  evident  from  the  above  that  the  prognosis  of  the  operation  is 
affected  favorably  by  the  removal  of  the  appendages  without  rupture 
and  escape  of  pus  into  the  pelvic  cavity.  The  average  mortality, 
however,  with  modern  asepsis  and  technique  should  not  exceed  2  per 
cent.,  except  for  acute  cases ;  usually  these  are  treated  more  safely  by 
vaginal  incision  and  drainage. 

Treatment  of  Salpingitis. 
The  treatment  will  be  found  in  the  two  following  chapters. 

OVARITIS. 

The  abdominal  end  of  the  Fallopian  tube  is  normally  close  to  the 
ovary  and  communicates  with  it  by  the  tubo-ovarian  ligament.  The 
utero-ovarian  ligament  connects  the  ovary  with  the  uterus.  Between 
the  insertions  of  these  two  ligaments  the  ovary  is  joined  to  the  pos- 
terior fold  of  the  broad  ligament  by  a  broad  base,  the  hilum,  through 
which  pass  the  lymphatics,  blood-vessels,  and  nerves.  Above  the 
hilum  the  ovary  is  covered,  not  by  peritoneum,  but  by  germ  epithe- 
lium, so  called,  which  forms  the  Graafian  follicles  and  from  which  the 
ova  originate.  The  anatomy  of  the  ovary  will  be  considered  further 
in  the  chapters  on  Ovarian  Tumors. 

Etiology  of  Ovaritis. 

Adhesions  between  the  tube  and  ovary,  especially  when  recent, 
contain  many  lymph-vessels ;  hence,  bacteria  may  have  a  short  acces- 
sible route  from  the  tube  to  the  ovary.  Accordingly,  inflammation 
of  the  ovary  is  usually  secondary  to  that  of  the  tube.  It  may,  how- 
ever, occur  independently  of  salpingitis  by  extension  from  distant 
organs  or  directly  from  the  peritoneum.  Among  the  bacterial  excit- 
ing causes  the  most  frequent  are  these  : 

1.  Gonococcus.  4.  Tubercle  bacillus. 

2.  Colon  bacillus.  5.  Pneumococcus. 

3.  Streptococcus  and  staphylococcus.      6.  Typhoid  bacillus. 

Comparative  Pathology  of  Acute  and  Chronic  Ovaritis. 

Acute  ovaritis.  1  Chronic  ovaritis. 

1.  Usually  develops  by  extension  from  some  |     1.  Usually  develops  from  acute  ovaritis, 
adjacent  organ. 

2.  Ovary  enlarged,  tense,  and  elastic.  Blood- 
vessels congested.  Punctate  hemorrhages. 
Surface  on  cross-section  yellowish  red  and 
cedematous.  Adhesions  form  late  or  not  at  all. 
Exceptions :  in  gonorrhoea!  ovaritis  adhesions 
form  early. 


2.  Ovaries  at  first  swollen  and  hard;  later, 
surface  uneven,  nodular,  and  cystic.  Cross- 
section  shows  numerous  small  cystic  spaces. 
Tunica  albuginea  hard  and  scar-like.  Adhe- 
sions from  periovaritis  not  uncommon. 


1  Martin.    Die  Krankheiten  der  Eileiter. 


282    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 


Acute  ovaritis. 

3.  Small-cell  infiltratiou  of  stroma— intersti- 
tial ovaritis. 

4.  Vessels  congested  and  tortuous. 

5.  Superficial  epithelium  degenerated  and 
desquamated.  Small  hemorrhages,  cellular 
infiltration,  and  suppuration  about  follicles. 
Follicular  epithelium  degenerated.  Liquor 
foUiculi  becomes  turbid  from  the  presence  of 
round  cells  and  degenerated  epithelium. 


6.  Infection  of  follicles  from  peritoueum^  or 
Fallopian  tube. 

7.  Ovarian  abscess  may  occur:  a,  in  a  corpus 
luteum ;  b,  in  the  connective  tssue ;  c,  in  the 
Graafian  follicles.  Non-gonorrhceal  abscess 
usually  unilateral,  and  not  associated  with 
pyosalpinx ;  infection  usually  travels  through 
lymphatics  in  broad  ligament.  Gonorrhoeal 
abscess  usually  bilateral  and  an  extension  of 
double  salpingitis. 

8.  May  rupture  into  peritoneum  or  into  bowel 
or  bladder. 


Chronic  ovaritis. 

3.  Interstitial  connective  tissue  increased— 
interstitial  ovaritis. 

4.  Same. 

5.  Superficial  epithelium  degenerated  or  ab- 
sent. Small  white  bodies— coz-po/u  albicantes — 
and  hemorrhages  near  follicles.  Ovary  be- 
comes smaller  from  contraction  of  connective 
tissue.  Great  numbers  of  follicles  may  be  filled 
with  thick,  turbid,  bloody  fluid  or  may  become 
obliterated.  This  follicular  disease  is  known 
as  microcyslic  degeneration,  and  is  a  common  re- 
sult of  ovaritis ;  see  below.  Tunica  albuginea 
thickened  and  may  be  hyaline 

6.  Same. 

7.  Same. 

See  Tubo-ovarian  Abscess  and  Tubo-ova- 
rian  Cyst  under  Salpingitis. 

Tubo-ovarian  abscess  found  by  Martin 
18  times  in  110  ovarian  abscesses. 


8.  Same. 


of 


IJ 


Physical  Signs  of  Ovaritis. 

The  physical  signs  of  ovaritis  are : 

1.  Increase  in  size  of  ovary. 

2.  Tenderness  and  sickening  sensation  in  ovary  on  digital  pressure. 
.3.  Displacement  of  ovary  common,  usually  backward  to  cul-de-sac 
Douglas,  and  consequent  upon  retroposition  of  uterus. 

4.  Ovary  immobile,  if  adherent ;  mobile,  if  not  adherent. 
See  physical  signs  of  salpingitis. 


Symptoms  and  Diagnosis  of  Ovaritis. 

Mild  ovaritis  commonly  is  associated  with  catarrhal  endometritis 
and  salpingitis.  Severe  ovaritis  usually  is  complicated  with  pelvic 
peritonitis  and  suppurative  salpingitis. 

Ovarian  abscess  is  difficult  to  recognize  ;  it  is  characterized  by 
swelling  and  pain,  and  may  give  rise  to  general   sepsis. 

The  following  symptom-group  will  aid  in  the  diagnosis  : 

1.  Pain  located  in  ovarian  region,  radiating  to  back,  thighs,  ischiatic 
nerves,  navel,  and  breasts. 

2.  Fever — not  a  constant  nor  reliable  symptom. 

3.  Nausea  and  vomiting — frequent. 

4.  Hemorrhage  from  uterus — not  uncommon. 

5.  In  severe  septic  cases  of  general  pelvic  infection  local  signs  are 
masked. 

6.  Recurrence — usual  in  chronic  cases. 

7.  Painful  defecation  and  frequent  urination. 

8.  Dyspareunia,  hysteria. 

In  chronic  cases  the  ovary  is  contracted  and  less  painful  on  press- 
ure. The  general  symptoms — i.  e.,  chill,  fever,  nausea  and  vomiting — 
are  absent,  and  the  history  will  show  long-standing  irritation  and  dis- 
comfort in  the  ovarian  region.  Microcystic  degeneration  is  associated 
often  with  amenorrhoea,  dysmenorrhoea,  and  sterility.  See  Chapters 
LIII.  and  LIV. 


INFLAMMATION  OF  THE    UTERINE  APPENDAGES. 


283 


Differential  Diagnosis  of  Ovaritis. 


Ovaritis. 

1.  lu  uncomplicated  ovaritis  inflammatory 
signs  localized  in  ovary  and  sharply  circum- 
scribed. 

2.  Ovary  usually  mobile. 

Ovaritis. 

1.  Ovary  enlarged  and  tender. 

2.  Pain  more  or  less  constant. 

3.  History  of  pelvic  infection. 

Ovaritis. 

1.  Commonly  bilateral. 

2.  Tends  to  localize  in  pelvis. 

3.  Digestive  disturbances  secondary. 

4.  Absence  of  tenderness  at  McBurney's 
point. 

5.  Inflammatory  lesion  deep  in  pelvis. 

6.  Inflamed  organ  recognized  by  size,  form- 
and  relation  to  Fallopian  tube. 


Pelvic  peritonitis  and  cellulitis. 

1.  Inflammation  may  involve  whole  pelvis — 
11-deflned. 

2.  Ovary  usually  fixed. 

Ovarian  neuralgia. 

1.  Ovary  may  be  normal. 

2.  Pain  inconstant. 

3.  No  such  history. 

Ajipendicitis. 

1.  Confined  to  right  side. 

2.  Tends  to  involve  abdominal  cavity. 

3.  Primary. 

4.  Usually  present. 

5.  High  in  iliac  space. 

G.  Ovary  often  recognized  by  bimanual  ex- 
amination as  being  separate  and  distinct  from. 
inflammatory  area. 


Treatment  of  Ovaritis. 
The  treatment  will  be  found  in  the  two  following  chapters : 


PELVIC  PERITONITIS. 

Pathology  and  Description  of  Pelvic  Peritonitis. 

The  two  principal  forms  of  peritonitis  are  : 

1.  Exudative  peritonitis. 

2.  Plastic  or  adhesive  peritonitis. 

The  two  forms  usually  occur  together.  The  plastic  form,  how- 
ever, has  been  observed  with  little  or  no  exudate.  In  addition  may 
be  mentioned  tubercular  peritonitis  and  pachyperitonitis. 

Exudative  Peritonitis  is  the  result  of  infection  which  does  not 
set  up  adhesions,  and  therefore  does  not  strongly  tend  to  provoke  de- 
fensive action,  is  more  liable  than  the  plastic  variety  to  become  gen- 
eral, and  for  this  reason  is  more  dangerous. 

Plastic  or  Adhesive  Peritonitis  is  characterized  by  the  formation 
of  adhesions  which  tend  to  shut  oflp  and  localize  the  infection  and  to 
prevent  it  from  extending  to  the  general  peritoneum  ;  the  infection 
thereby  is  limited  not  only  in  extent  and  quantity,  but  its  force  is 
spent  within  narrow  limits  within  which  the  process  may  be  very 
intense  and  the  part  may  be  sacrificed  for  the  benefit  of  the  whole. 
See  remarks  on  Acute  Inflammation  and  the  Significance  of  Inflam- 
mation, in  Chapters  X.  and  XIX.  The  maximum  of  exudate  with 
the  minimum  of  defensive  adhesion  is  dangerous ;  conversely,  tlie 
minimum  of  exudate  with  the  maximum  of  adhesion  is  relatively 
safe. 

Pelvic  peritonitis  usually  begins  with  perimetritis  or  perisalpin- 
gitis, the  infection  having  reached  the  peritoneum  from  the  uterine 
or  tubal  mucosa.  Sometimes  the  origin  is  extrapelvic  ;  in  such  cases 
the  uterus  and  uterine  appendages  may  not  be  involved.     The  disease, 


284   INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

especially  in  connection  with  gonorrhoeal  salpingitis,  is  very  common. 
The  frequent  recurrence  of  acute  local  exacerbations  furnishes  a 
familiar  indication  for  the  removal  of  the  uterus  and  the  uterine 
appendages. 

The  exudate  consequent  upon  infection  of  the  peritoneum  may  be 
serous  or  purulent ;  it  may  or  may  not  be  mixed  with  blood.  In  the  plas- 
tic form  protective  adhesions  often  make  numerous  partitions  through 
the  infected  parts ;  hence  several  distinct  collections  of  fluid  may  be 
formed.     These  collections  are  sometimes  serous  in  one  part,  purulent 


FiouEE  124. 

1 

l^i 

1 

f      ^i^^^^^tt^^i 

u  _^ 

wBt^ 

p 

Right  and  left  pyosalplnx;  adhesions  to  uterus    rectum,  and  vermiform  appendix.    Co, 
colon;  C,  cfficum;  R,  rectum;  Rt,  right  Fallopian  tube.    Lt,  left  Fallopian  tube.    U,  uterus. 

in  another,  and  hemorrhagic  in  another ;  the  whole  may  form  a  tumor 
filling  the  pelvis  and  the  lower  part  of  the  abdomen,  and  having  the 
appearance  and  many  of  the  physical  signs  of  an  ovarian  cyst.  The 
adhesions  may  be  broken  up  gradually  by  movements  of  the  intes- 
tine and  by  absorption,  or  they  may  become  firm  and  permanent ; 
hence  the  organs  may  be  matted  strongly  together  Avith  resultant  dis- 
placement, stenosis,  stricture,  occlusion,  kinking,  embarrassed  peris- 
talsis, and  defective  general  nutrition.  The  fluid  may  be  absorbed  or 
may  break  into  a  neighboring  organ.     In  the  latter  way  communica- 


INFLAMMATION  OF  THE   UTERINE  APPENDAGES.  285 

tions  may  be  formed  between  the  pelvic  cavity,  and  the  bowel,  blad- 
der, or  vagina.  Sometimes  the  pus  finds  its  way  to  the  cutaneous 
surface.  Accumulations  are  most  frequent  in  the  pouch  of  Douglas. 
The  microscopical  findings  show  a  few  round  cells  in  the  serous, 
numerous  pus-cells  with  a  few  red-blood-corpuscles  in  the  purulent, 
and  numerous  white  and  red  blood-corpuscles  in  the  hemorrhagic  col- 
lections. 

Tubercular  Peritonitis  is  of  frequent  occurrence,  and  usually  is 
characterized  by  small,  sometimes  minute,  pearly  tubercles  or  points 
scattered  over  the  peritoneum. 

The  essential  cause  is  the  bacillus  tuberculosis.  The  source  of  the 
infection  is  usually  tubercular  ulceration  of  the  bowel,  general  tuber- 
culosis, or  localized  tuberculosis  of  the  Fallopian  tubes  or  other  pelvic 
viscera.     The  disease  is  rarely  primary. 

The  pathology  differs  from  that  of  ordinary  peritonitis  in  the  fol- 
lowing particulars : 

1.  The  peritoneum  is  studded  with  miliary  tuberculosis,  of  which 
the  tubercles  may  be  large  and  caseous. 

2.  The  fluid  exudate  (serous,  hemorrhagic,  or  purulent)  appears 
later,  and  in  numerous  places  may  be  encysted. 

3.  The  peritoneal  viscera  usually  are  matted  together  by  adhesions. 

4.  The  mesenteric  glands  may  be  enlarged  and  palpable. 

5.  The  bowel  may  become  perforated  or  obstructed. 
Pachyperitonitis. — Oftentimes  the  peritoneum  is  much  thickened 

by  the  formation  upon  its  surface  of  new  membrane,  which  gives  it  a 
leathery  appearance.  The  vessels  in  this  new  membrane  early  rupture 
with  circumscribed  hemorrhage.     This  is  called  pachyperitonitis. 


Symptoms  of  Pelvic  Peritonitis. 

The  symptoms  in  the  acute  stage  vary  within  wide  limits  ;  may  be 
quite  disproportionate  to  the  gravity  of  the  infection  ;  may  be  slight 
or  absent ;  or  may  include  great  pain,  nausea,  fever,  abdominal  dis- 
tention, retraction  of  the  thighs,  anxious  facies,  and  profound  nervous 
depression.  The  greater  the  tendency  of  the  peritonitis  to  become 
general  the  more  aggravated  will  be  the  symptoms.  The  chronic 
results  of  peritonitis  include  great  discomfort,  pain,  and  disturbance 
of  function  in  the  pelvis,  especially  about  the  rectum,  uterus,  and 
bladder.  These  symptoms  may  come  largely  from  mechanical  causes, 
such  as  tension  on  bands  of  adhesion  and  pressure  and  traction  upon 
the  inflamed  peritoneum. 

The  distinctive  symptoms  of  tubei'cular  peritonitis  are  :  1,  gradual 
onset ;  2,  diffiise,  not  severe,  pain  in  the  abdomen  ;  3,  febrile  con- 
dition and  temperature  highest  at  night;  4,  rapid,  often  irregular 
pulse,  with  meteorism ;  5,  sweating,  general  malaise,  relapses,  and 
remissions. 

The  special  local  signs  of  tubercular  peritonitis  are  :  1,  enlargement 
of  the  abdomen ;  2,  local  or  general  tenderness  on  pressure  ;  3,  dul- 
ness  on  percussion  over  involved  areas. 


286    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Diagnosis  and  Differential  Diagnosis  of  Pelvic  Peritonitis. 

The  diagnosis  and  differential  diagnosis  have  been  given  under 
Pelvic  Cellulitis,  Salpingitis,  and  Ovaritis. 

Treatment. 

The  treatment  of  pelvic  perit'>nitis  will  be  found  in  the  two  follow- 
ing chapters. 


CHAPTEE  XXII. 

NON-SURGICAL  TREATMENT  OF  PELVIC  INFLAMMATION 
—SALPINGITIS,  OVARITIS,  AND  PELVIC   PERITONITIS. 

The  noii-surgical  treatment  of  inflammation  of  the  uterine  apjDen- 
dages  is : 

1.  General. 

2.  Local. 

1.  General  Non-surgical  Treatment. 

The  treatment  of  the  milder  adnexel  inflammation,  when  early 
recognized,  is  largely  the  same  as  that  of  the  causative  endometritis. 
Quiet,  frequent  rest,  judicious  active  and  passive  exercise,  avoidance 
of  sexual  excitement,  regulation  of  the  bowels,  nutritious  and  non- 
stimulating  diet,  and  the  prohibition  of  tea  and  coffee  in  neurotic 
cases,  are  among  the  routine  measures  as  stated  under  Diagnosis. 
Repeated  examinations  and  treatments,  especially  rough  palpation  of 
a  sactosalpinx,  may  prove  dangerous. 

Medical  Treatment. — The  occasional  practice  in  acute  cases  of 
locking  up  the  bowels  and  preventing  peristalsis  by  the  free  use  of 
opium  has  largely  been  abandoned.  On  the  contrary,  rather  active 
elimination  through  the  bowels  and  kidney  has  become  the  more 
accepted  practice.  Pain  may  be  relieved  by  opium  and  its  deriva- 
tives ;  but  they  mask  the  symptoms  and  check  the  secretions,  and 
therefore  in  a  degree  are  contraindicated  ;  hence  non-constipating  pal- 
liatives usually  are  substituted  for  opium.  Of  these,  the  coal-tar  deriva- 
tives, chloral  hydrate,  hyoscyamus,  and  sodium  bromide  are  among 
the  more  useful  and  least  objectionable.  The  codeine  phosphate 
repeated  in  half-grain  doses  is  perhaps  the  least  objectionable  of  the 
preparations  of  opium.  Should  the  nervous  symptoms  predominate 
and  demand  the  more  dependable  morphine,  the  constipating  efi^ect 
may  be  overcome  by  the  addition  of  an  equal  amount  of  podo])hylIin. 

Elimination  often  is  secured  well  by  means  of  rectal  enemata  con- 
taining magnesium  sulphate,  glycerin,  or  spirit  of  turpentine,  or,  if 
positive  purging  be  required,  by  the  use  of  some  active  cathartic. 
One  may  use  to  advantage  repeated  doses  of  calomel,  one-half  grain 
in  each,  followed  by  Rochelle  salt,  solution  of  magnesium  citrate,  or 
some  other  appropriate  saline.  When  the  stomach  will  not  tolerate 
ordinary  cathartics,  a  grain  of  calomel  may  be  put  upon  the  tongue 
every  hour  until  the  bowels  act.  A  very  high,  retained  enema  of 
four  ounces  of  the  saturated  solution  of  magnesium  sulphate  often 
gives  prompt  relief. 

There  is  a  form  of  chronic  bilateral  adnexal  disturbance  which 
scarcely  goes  beyond  irritation  and  congestion.     This  is  referred  sub- 

■287 


288    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

jectiyely  to  the  region  of  the  ovaries.  It  is  quit€  common  among 
nervous,  overwrought  spinsters  and  girls,  is  associated  usually  with 
nervous  irritability,  is  sometimes  transient,  often  intractable,  seldom 
dangerous.  Overwork  and  overexcitement,  says  Lawson  Tait,  from 
study  or  social  requirements,  and  especially  the  pursuit  of  music,  by 
the  physical  strain  of  practice  and  by  the  power  of  music  to  excite  the 
emotions  at  the  developmental  period  of  puberty,  are  potent  and, 
among  the  higher  classes,  common  causes  of  ovarian  irritation.  Many 
a  hopeless  neurotic  invalid  may  in  mature  life  date  her  invalidism 
from  mental  and  emotional  strains  at  the  time  of  puberty.  The  treat- 
ment of  this  indefinite  irritation  should  be  mainly  hygienic  and  moral 
—that  is,  rather  regulative  than  medicinal.  Unsatisfied  sexual  re- 
quirements, conscious  or  unconscious,  demand  that  the  attention  be 
drawn  away  from  the  reproductive  organs.  If  the  patient  has  reached 
the  proper  age,  marriage  may  be  desirable ;  at  least  let  there  be  a 
change  of  environment  and  promotion  of  new  interests.  A  careful, 
all-around  examination  may  show  some  causal  and  removable  extra- 
pelvic  fault  in  the  patient  or  her  environment.  There  will  often  be 
found  disturbance  of  the  heart,  liver,  or  kidney  or  intestinal  indiges- 
tion, and  such  disorders  may  explain  the  conditions  upon  which  the 
ovarian  irritation  depends.  There  is  usually  an  associated  mild  endo- 
metritis, which  yields,  if  at  all,  to  systemic  treatment.  The  useless 
sacrifice  of  countless  ovaries  in  this  class  of  cases  is  a  reproach  to  sur- 
gery. Menorrhagia,  if  associated  with  this  condition,  is  Avell  treated 
by  ergot,  preferably  given  in  rectal  suppositories,  five  to  ten  grains 
every  eight  hours  until  the  flow  is  controlled. 

Skene  recommends  for  menorrhagic  and  neurotic  cases  the  con- 
tinued use  of  the  fluid  extract  of  hydrastis  in  thirty-drop  doses,  and, 
as  needed  for  nervousness  and  sleeplessness,  twenty  to  thirty  grains 
of  sodium  bromide,  to  be  given  well  diluted  at  bedtime,  and  repeated 
if  necessary. 

The  medical  treatment  not  only  of  the  above  form  of  ovarian  irri- 
tation, but  of  chronic  adnexal  inflammation  in  general,  includes  the 
judicious  use  of  tonics,  laxatives,  alteratives,  and  hypnotics.  It  must 
conform  to  the  general  principles  of  internal  medicine,  and  differs  in 
no  essential  point  from  the  general  treatment  of  similar  extrapelvic 
disorders. 

Local  Non-surgical  Treatment. 

Mechanical  support  for  the  uterus,  if  displaced,  may  open  up 
the  collapsed  uterine  canal,  secure  drainage  of  retained  secretions, 
and  by  overcoming  traction  on  the  blood-vessels  may  relieve  con- 
gestion. 

Cold-water  coils  or  the  rubber  ice-bag  applied  to  the  abdomen,  or 
the  application  of  a  large  blister  to  that  part  of  the  hypogastrium 
which  lies  over  the  seat  of  maximum  pain,  and  the  free  use  of 
leeches,  may  be  serviceable,  especially  in  the  abortive  treatment  of 
acute  cases.  At  least  eight  leeches  should  be  applied  :  one  or  two  are 
useless. 

The  local  treatment  of  chronic  adnexal  inflammation  has  for  its 


NONSURGICAL   TREATMENT  OF  SALPINGITIS.  289 

chief  object  the  quickening  of  the  pelvic  circulation  and  the  promo- 
tion of  absorption  of  morbid  products.  It  includes  :  1,  the  hot-water 
vaginal  douche ;  2,  the  vaginal  tamponade  of  lamb's  avooI  saturated 
with  glycerin  or  glycerin  and  ichthyol ;  3,  the  hot  hip-pack ;  4,  elec- 
tricity ;  5,  massage. 

The  hot-water  vaginal  douche  and  the  ivool  vaginal  tamponade  are 
described  in  Chapter  IV. 

Hot  Hip-pack. — The  application  of  the  hot  hip-pack  is  as  follows  : 
Let  an  ordinary  sheet  be  folded  lengthwise  into  several  thicknesses, 
so  that  its  width  will  reach  from  the  umbilicus  to  the  middle  of  the 
thighs.  Let  this  be  made  into  a  roller  bandage,  dipped  in  very  hot 
water,  and  wrung  as  nearly  dry  as  possible,  preferably  by  a  clothes- 
wringer.  Pass  this  bandage  several  times  around  the  pelvis,  so  as  to 
envelop  the  zone  from  the  umbilicus  to  the  middle  of  the  thighs. 
Cover  it  with  a  dry  sheet  and  let  the  patient  lie  in  it  for  thirty  min- 
utes. It  is  well,  in  order  to  retain  the  heat  as  long  as  possible,  to 
place  between  the  wet  and  dry  sheet  a  rubber  sheet,  a  rubber  bag  of 
hot  water,  or  the  electric  heating  pad.  The  pack  repeated  daily,  or 
twice  daily,  according  to  the  tolerance  of  the  patient,  is  a  most  effi- 
cient means  of  stimulating  the  pelvic  circulation,  and  thereby  of  pro- 
moting absorption  of  morbid  products.  Chronic  constipation,  pelvic 
pain,  dysmeuorrhoea,  and  other  functional  disturbances  often  give  way 
promptly  under  its  influence. 

Electricity. — The  galvanic  electrode,  even  with  light  dosage,  has 
caused  repeatedly  extensive  destruction  and  cicatricial  contraction  in 
the  genital  tract,  especially  in  the  upper  part  of  the  vagina.  The 
intra-uterine  electrode  is  painful,  often  intolerable,  and  the  occasional 
cause  of  dangerous  infection.  The  faradic  current  is  used  as  a  means 
of  deep  local  massage,  and  the  galvanic  for  its  supposed  resolvent 
effects.  Both  are  said  to  promote  absorption.  The  electrical  treat- 
ment has  proved  itself  neither  in  safety  nor  efficiency  equal  to  the 
promise  of  its  devotees. 

Massage. — General  massage  is  recognized  as  a  measure  of  great 
value. 

Local  massage  after  the  method  of  Thure  Brandt  is  recommended 
for :  1,  the  removal  of  inflammatory  exudates  ;  2,  the  breaking  up 
and  stretching  of  adhesions ;  3,  the  restoration  of  function  to  con- 
tracted or  overstretched  ligaments  ;  4,  the  reposition  of  displaced 
organs.  The  application  of  local  massage  requires  more  technical 
skill  than  the  physician  would  possess  unless  he  had  received  long 
and  special  preparatory  training.  The  objection  commonly  and 
strongly  urged  against  massage,  that  it  may  excite  sexual  reflexes 
and  produce  erotic  feelings,  is  important ;  this  objection,  however, 
provided  that  proper  methods  and  precautions  are  enforced,  need  not 
necessarily,  in  selected  cases,  have  prohibitory  force ;  that  is,  properly 
conducted  massage  in  a  suitable  case  should  not  provoke  erotic  feel- 
ings. The  tendency  to  erotic  excitement  would  usually  l)e  counter- 
acted by  the  discomfort  which  the  manipulation  necessarily  entails 
upon  the  patient ;  moreover,  a  subject  of  erotic  tendencies  would 
clearly  be  unfit  for  the  treatment.     Much  depends  upon  the  individ- 

19 


290    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

uality  of  the  operator,  and  upon  the  observance  of  an  inviolable  rule 
that  the  left  hand  and  especially  the  finger  in  the  vagina  be  kept  per- 
fectly motionless,  away  from  the  clitoris  and  against  the  posterior 
wall  of  the  vagina.  The  massage  is  given  entirely  with  the  right 
hand  over  the  abdomen.  Obviously  the  treatment  if  adopted  at  all 
should  be  given  by  a  technically  trained  M'oman.  The  value  of  the 
method  probably  has  been  overestimated. 


CHAPTER    XXIII. 

SURGICAL  TREATMENT  OF  SALPINGITIS,  OVARITIS,  AND 
PELVIC   PERITONITIS. 

When  the  disease  has  progressed  to  permanent  obstruction  of  the 
Fallopian  tube  and  the  formation  of  pyosalpinx,  and  especially  when 
occasional  attacks  of  local  peritonitis  prove  that  the  infection  is  not 
constantly  confined  to  the  tube,  a  radical  operation,  even  to  the  re- 
moval of  the  diseased  organs,  may  be  less  dangerous  than  the  disease, 
and,  relatively  speaking,  therefore,  it  may  become  a  conservative 
measure.  The  inflamed  tube,  enlarged  to  the  size  of  the  finger,  will 
seldom  return  to  its  normal  state  and  functions,  and  if  also  there  be 
evidence  of  suppuration  or  great  local  irritation,  the  indication  for 
operation  is  clear. 

For  the  preparatory  treatment,  see  Chapter  II. 

The  removal  of  the  Fallopian  tube  alone  is  called  salpingectomy ; 
that  of  the  ovary  alone  is  called  oophorectomy  ;  the  removal  of  the 
tube  and  ovary  is  designated  as  oophoro-salpingectomy,  or  salpingo- 
odphorectomy.  The  simple  English  expression,  removal  of  the 
uterine  appendages,  would  seem  more  appropriate.  Usage  reserves 
the  word  ovariotomy  to  signify  the  removal  of  an  ovarian  tumor. 

EOUTES  OF   OPERATION. 

There  are  two  recognized  routes  for  the  removal  of  inflamed  uterine 
appendages — the  abdominal  and  the  vaginal.  An  operation  by  the 
abdominal  route  necessitates  abdominal  section,  also  called  coeliotomy 
or  laparotomy.  An  operation  by  the  vaginal  route  involves  vaginal 
section.  It  is  sometimes  necessary  to  combine  abdominal  and  vaginal 
section  in  one  operation. 

Operation  by  Abdominal  Section. 

The  reader  is  referred  to  Chapters  II.,  VI.,  VII.,  and  VIII.  for 
preparatory  treatment,  for  the  technique  of  abdominal  section,  and  for 
the  general  conduct  of  the  operation.  It  is  often  necessary  to  add  to 
this  operation  a  vaginal  section,  hence  the  importance  of  making  in 
the  vagina  and  about  the  vulva  the  same  aseptic  preparations  as 
would  be  made  if  vaginal  section  were  planned  from  the  beginning. 

Sometimes  the  inflammatory  exudate  has  extended  through  the 
peritoneum  to  the  subperitoneal  structures,  and  so  disorganized  and 
disguised  the  parts  as  to  render  them  difficult  of  recognition.  Under 
these  conditions  careful  dissection  is  necessary,  in  opening  the  abdo- 
men, to  avoid  the  unfortunate  accident  of  opening  directly  through 

291 


292    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

the  thickened,  leathery  peritoneum  into  an  adherent  bladder  or 
intestine. 

During  an  operation  tlie  surrounding  peritoneum  should  be  pro- 
tected against  possible  rupture  of  tubal  or  ovarian  abscesses  by  the 
free  use  of  sponges  so  placed  as  to  absorb  any  escaping  fluid.  In  all 
operations  sponges  should  be  of  gauze,  should  always  be  used  dry, 
and  as  soon  as  they  become  saturated  should  be  discarded  for  other 
dry  ones.  The  special  assistant  who  formerly  washed  sponges  is  no 
longer  required,  but  may  be  utilized  for  counting  and  keeping  track 
of  sponges  so  that  none  shall  be  lost  in  the  abdominal  cavity. 

If  adherent  omentum  is  in  the  way,  it  may  be  separated  gently 
with  the  sponge — that  is,  sponged  off  from  its  attachments.  If  not 
adherent,  it  may  be  pushed  aside.  Bleeding  points  should  be  secured 
by  fine  catgut  ligatures,  torsion,  or  temporary  forcipressure. 

If  the  case  be  simple,  with  no  adhesions,  or  if  the  adhesions  be 
few  and  easily  broken,  the  operation  will  be  relatively  simple.  The 
index-finger  of  the  left  hand  finds  the  fundus  and  posterior  wall  of 
the  uterus,  and  then  maps  out  the  diseased  areas  in  that  region. 
The  finger,  starting  from  the  posterior  wall  of  the  uterus,  sweeps 
aloTig  the  posterior  fold  of  the  broad  ligament  on  either  side  and 
examines  the  Fallopian  tubes  and  ovaries.  These  organs,  now  acces- 
sible to  sight  and  touch,  may  be  subjected  to  any  necessary  operation 
or  manipulation.  The  incision,  if  too  short,  may  be  lengthened.  The 
intestine  is  pushed  upward  and  isolated  by  flat  gauze  sponges.  If 
there  are  no  adhesions,  the  appendages  may  be  lifted  gently  up  into 
the  wound  and  examined.  The  surrounding  exposed  parts  should 
be  protected  by  gauze  sponges.  If  removal  of  the  appendages  is 
necessary,  the  operation  as  ordinarily  performed  is  as  follows : 

It  is  of  the  utmost  importance  to  remove  every  particle  of  tubal 
tissue,  cutting  it  out  clear  into  the  tissue  of  the  uterus.  Failure  to  do 
this  often  results  in  the  formation  of  stump  exudates  which  perpetuate 
the  evils  of  salpingitis  in  exaggerated  form  and  may  necessitate  addi- 
tional surgery  for  the  removal  of  the  offending  stump. 

Place  a  ligature  on  the  infundibulopelvic  ligament — i.  e.,  on  that 
portion  of  the  broad  ligament  between  the  ovary  and  the  w^all  of  the 
pelvis.  Place  another  ligature  on  the  other  end  of  the  broad  ligament 
where  it  joins  the  uterus.  This  ligature  should  not  include  the  Fallo- 
pian tube.  These  two  ligatures  shut  oif  the  ovarian  vessels  and  should 
render  the  remaiuder  of  the  operation  almost  bloodless.  Grasp  the 
tube,  ovary,  and  adjacent  portion  of  the  broad  ligament  in  the  left  hand, 
and  with  the  scissors  remove  them.  As  these  parts  are  severed  bleeding 
points  may  be  secured  by  temporary  forcipressure.  Fine  catgut  liga- 
tures are  now  placed  upon  any  bleeding  point  between  the  two  ligatures 
already  tied. 

Author's  Reefing  Operation. — This  operation  is  designed  to 
shorten  and  strengthen  the  ligament  and  to  limit  the  traumatism,  and 
thereby  to  secure  the  uterus  against  descent  and  backward  displace- 
ment. If  there  is  great  tendency  to  descent  or  retroposition,  the  round 
ligaments  also  may  be  drawn  into  the  broad  ligament  wound  and 
shortened  by  including  them  in  the  broad  ligament  sutures.  The 
method  obviates  the  necessity  of  such  supplementary  operations  as 


SURGICAL   TREATMENT  OF  SALPINGITIS.  293 

Figure  125. 


V^^J^ 

> 

ki   -■■■'i:   -■   ^j^^^^^^^^^^^^B^^^^I^^I^^^^H^^^ 

y 

Removal  of  uterine  appendages,  first  step.  Tlie  tube  lias  been  freed  from  the  adliesions  and 
drawn  up  into  the  abdominal  wound ;  one  catgut  ligature  passed  around  the  ovarian  artery  as 
it  runs  through  the  infundibulopelvic  ligament  and  another  as  it  enters  the  uterus.  The  right 
side  shows  the  ligatures  passed,  but  not  tied  ;  the  left  side  shows  them  tied  and  the  tube  and 
ovary  being  excised  by  means  of  scissors. 

Figure  126. 


Removal  of  uterine  appendages,  second  step.  Ligatures  on  ovarian  vessels  drawn  tight  and 
tied,  and  tubes  and  ovaries  removed.  Any  snrall  bleeding  points  in  the  cut  surface  between 
the  two  ligatures  that  secure  the  ovarian  artery  should  be  tied  by  tine  catgut  ligatures.  On  left 
side,  cut  edge  of  broad  ligament  being  closed  by  author's  reefing  suture  in  such  a  way  as  to  fold 
cut  edge  on  itself  and  thereby  strengthen  and  "shorten  the  ligament.  On  right  side  closure  of 
ligament  complete. 

hysterorrhaphy  and  vaginal   hysteropexy,  and  is  therefore  specially 
applicable  to  cases  in  which  there  are  great  relaxation  of  the  broad 


294  INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

ligaments  and  consequent  descent  of  the  pelvic  organs.  Figures  ]  25 
and  126. 

The  usual  method  of  closing  the  broad  ligament  M^ound  is  shown 
in  Figure  127.  Observe  the  glover's  stitch  and  method  of  introduc- 
tion in  the  whipping  together  the  cut  edge  of  the  ligaments  on  them- 
selves.    This  method  is  not  advised  when  the  ligaments  are  relaxed. 

Figure  128  illustrates  removal  of  an  ovary  without  sacrifice  of  the 
tube.  Figure  129  shows  removal  of  a  Fallopian  tube  without  sacrifice 
of  the  ovary. 

Complications  in  the  Removal  of  the  Uterine  Appendages. — 
The  difiGuUies  and  dangers  of  the  operation  may  be  small  or  may  be 
so  great  as  to  make  it  one  of  the  most  formidable  in  surgery.     The 

Figure  127. 


Removal  of  uterine  appendages,  final  step.    Showing  the  glover's  stitch  and  the  method 

of  introduction. 

special  technique  to  meet  the  varied  conditions  turn  upon  the  presence 
or  absence  of  pus  or  of  adhesions. 

Technique  in  Pus  Cases. — Although  the  pus  in  chronic  pyosalpinx 
is  usually  sterile,  it  is  not  always  so ;  hence  it  is  safer  to  proceed  on 
the  supposition  that  all  pus  or  other  fluid  is  infectious,  and,  if  possible, 
therefore  to  enucleate  the  sac  without  breaking  it.  Aspiration  of  a 
part  of  the  fluid  from  a  very  tense  tube  may  decrease  the  risk  of 
rupture.  Contact  of  the  pus  of  a  ruptured  tube  with  the  peritoneum 
may  have  no  serious  results,  for : 

1.  The  fluid  may  be  sterile,  and  therefore  innocent. 

2.  Even  though  infectious,  if  thoroughly  washed  out  with  normal 
salt  solution  (Chapter  VII.),  the  residue  of  septic  matter,  now  much 
diluted,  may  be  taken  up  by  the  peritoneum  and  thrown  off"  by  the 


Figure  128. 


Eemoval  of  ovary ;  tube  being  normal,  is  not  removed. 
Figure  129. 


Removal  of  Fallopian  tube ;  ovary  being  normal,  is  uot  removed. 


295 


2QQ  INFECTIONS,   INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

organs  of  elimination.  The  capacity  of  the  peritoneum  to  absorb  and 
throw  off  such  matter  is  sometimes  very  great.  The  conditions,  how- 
ever, under  which  it  does  or  does  not  do  so  are  not  fully  known.  See 
Chapter  YIL,  on  Drainage. 

The  coexistence  of  pyosalpinx  and  a  communicating  parametric 
abscess  clearly  renders  the  clean  enucleation  of  the  pus-sac  impossible. 
After  removal  of  such  a  tube  the  parametric  abscess  cavity  will  be 
in  direct  communication  with  the  pelvic  cavity,  and  this  will  necessi- 
tate a  free  opening  from  the  cul-de-sac  of  Douglas  into  the  vagina  and 
eifective  gauze  drainage  by  that  route.  Figure  71.  If  possible,  the 
general  abdominal  cavity  should  be  shut  off  by  stitching  the  omentum 
or  peritoneum  over  the  abscess-wall  as  shown  in  Figure  180.  If 
there  be  a  parametric  abscess  pure  and  simple,  without  tubal  or  other 
connections,  the  pus  is  much  better  evacuated  and  drained  preferably 
by  the  vaginal  rather  than  by  the  abdominal  route.  In  some  cases 
even  with  tubal  involvement  the  vaginal  route  is  preferable. 

When  the  pelvic  viscera  are  matted  together  with  strong  and 
extensive  adhesions,  including  a  great  quantity  of  inflammatory 
infiltrate  and  pus,  hysterectomy  and  vaginal  drainage  may  be 
necessary  in  addition  to  the  removal  of  the  uterine  appendage ;  such 
operations  furnish  much  of  the  mortality  in  odphoro-salpingectomy. 
The  danger  may  be  so  great  as  even  to  prohibit  the  radical  operation, 
and  to  require  instead  the  more  conservative  measure  of  simple  incision 
and  drainage  by  the  vaginal  or  abdominal  route.  Sometimes  the 
adhesions  between  the  visceral  peritoneum  covering  the  abscess  and 
the  parietal  peritoneum  through  which  the  abdominal  incision  is  made 
are  so  extensive  that  the  operator  may  find  his  way  directly  into  the 
pus-cavity  without  exposure  of  the  general  peritoneum.  In  such  a  case 
it. is  wise  not  to  attempt  removal  of  the  appendages,  nor  even  to  make 
a  complete  diagnosis,  but  rather  to  locate,  incise,  and  drain  the  pus- 
cavity.  A  more  radical  operation  may  be  made  later,  if  necessary. 
Upon  opening  the  abdomen  one  may  locate  a  pus-sac  adherent  to 
some  part  of  the  abdominal  wall  at  a  distance  from  the  incision  ;  it 
might  then  be  good  surgery  to  close  the  first  incision  and  make 
another  through  the  abdomen  or  vagina  directly  into  the  sac.  The 
abscess  could  then  be  evacuated  without  contamination  of  the 
peritoneum. 

The  indications  and  technique  of  washing  and  sponging  out  the 
peritoneal  cavity,  and  the  indications  and  modes  of  abdominal  drain- 
age and  the  toilet  of  the  peritoneum,  are  set  forth  under  the  General 
Principles  of  Peritoneal  Surgery,  in  Chapters  VI.  and  VII. 

Technique  in  Adhesions. — Strong  and  extensive  adhesions  are. 
among  the  most  common  difficulties  in  the  freeing  of  such  hopelessly 
diseased  organs  as  judicious  surgery  marks  for  removal.  The  first 
objective  point,  as  in  the  simple  cases,  is  the  fundus  and  the  posterior 
wall  of  the  uterus.  From  this  point  the  finger  searches  out  the  dis- 
eased uterine  appendages  on  either  side  and  recognizes  their  relations 
to  adjacent  structures.  An  ovary  or  tube,  even  though  imbedded  in 
apparently  inseparable  adhesions,  may  often  be  shelled  out  with  rela- 
tive ease  if  the  weaker  lines  of  cleavage  can  be  found  and  made 
the   starting-points  of  enucleation.     Let   the   tip    of  the    index   and 


SURGICAL   TREATMENT  OF  SALPINGITIS.  297 

middle  fingers  of  the  left  hand  search  for  sulci  between  the  diseased 
appendages  and  the  adherent  surfaces.  Follow  points  of  least  resist- 
ance so  long  as  the  separation  does  not  require  undue  force ;  then  look 
for  other  such  points.  The  finger  advances  with  gentle  firmness, 
using  the  side-to-side  and  to-and-fro  motion,  until  by  pressing  here 
and  there,  and  by  pinching  the  adherent  structures  apart,  the  outlines 
of  the  diseased  organs  are  made  clearer  and  clearer.  By  this  means 
they  finally  are  isolated  and  brought  up  into  the  wound.  The  tech- 
nique of  removal  is  then  the  same  as  for  non-adherent  appendages. 

Technique  in  Hemorrhage. — During  the  enucleation  it  is  not  well 
to  stop  for  minor  bleeding  points.  Let  the  organs  be  isolated  from 
the  bed  of  adhesions  as  rapidly  as  safety  will  permit.  Always  keep 
sponges  packed  around  to  control  hemorrhage  by  pressure  and  to 
absorl)  blood,  pus,  or  serum.  When  the  appendages  are  cut  off  and 
the  ordinary  ligatures  applied  the  bleeding  usually  will  have  ceased. 
If  not,  pack  hot  sponges  firmly  against  the  bleeding  surfaces,  fre- 
quently changing  them  to  prolong  the  heat.  A  sterilized  saturated 
solution  of  antipyrin,  as  recommended  by  Roswell  Park,  is  a  valuable 
hfemostatic.  If  bleeding  is  not  controlled  by  prolonged  hot-sponge 
pressure,  antipyrin,  and  ligature  of  the  ovarian  vessels,  and  the 
bleeding  points  cannot  be  secured  by  isolated  ligatures,  it  is  better  not 
to  prolong  the  operation  by  temporizing,  but  to  insure  hsemostasis  by 
immediate  ligature  of  the  uterine  arteries,  and  if  need  be  by  removal 
of  the  uterus.  The  ligature  is  applied  in  the  same  manner  as  for 
abdominal  hysterectomy. 

Technique  in  Abdominal  Hysterectomy. — If  in  the  course  of  the 
operation  the  indication  arises  for  removal  of  the  uterus,  the  operator 
must  proceed  to  it  at  once.  See  later  paragraphs  on  the  indications 
for  hysterectomy.  The  danger  now  will  increase  rapidly  with  delay. 
The  principles  and  technique  of  this  operation  differ  in  no  essential 
respect  from  those  of  complete  hysteromyomectomy  described  in 
Chapter  XXVII. 

The  abdominal  wound  should  be  closed  without  drain.  Drainage, 
if  used,  should  be  made  through  the  vagina,  the  gauze  drain  being 
introduced  through  the  abdominal  wound  and  carried  thence  into  the 
vagina. 

Technique  in  Intestinal  Opening. — Mention  has  been  made  of  the 
breaking  through  and  discharge  of  the  contents  of  a  pus-tube  into  an 
adherent  intestine.  The  enucleation  of  such  a  tube  necessarily  would 
leave  an  opening  in  the  intestine.  Some  provision  then  must  be 
made  to  keep  the  contents  of  the  bowel  from  escaping  through  this 
opening  into  the  free  abdominal  cavity.  There  are  several  possible 
plans  of  procedure  : 

1.  If  the  opening  is  small  and  accessible,  it  should  be  closed  with 
sutures  and  treated  according  to  the  requirements,  with  or  without 
abdominal  drainage. 

2.  If  the  opening  is  accessible  and  the  loss  of  bowel-wall  so  great 
that  repair  with  sutures  would  destroy  the  permeability  of  the  bowel, 
the  indication  is  for  resection  or  fi)r  stitching  the  opening  into  the 
abdominal  wound,  and  making  thereby  an  artificial  anus.  Unless 
contraindicated  by  the  exhausted  condition  of  the  patient,  resection 


298   INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

would  be  preferable,  for  if  the  artificial  anus  did  not  close  spontane- 
ously resection  would  have  to  be  made  subsequently. 

3.  If  the  opening  is  so  deep  in  the  pelvis  as  to  be  inaccessible  or 
the  patient  is  too  exhausted  to  permit  suture,  the  territory  around  the 
fistula  may  be  quarantined  from  the  general  peritoneum  by  means  of 
gauze  packing.  Adhesions  will  form  in  a  few  hours  around  the  pack- 
ing and  thereby  shut  oif  the  leaking  bowel  from  the  general  perito- 
neum. The  writer  has  treated  successfully  two  cases  by  this  method. 
The  gauze  may  be  brought  out  through  the  abdominal  wound ;  or  if 
the  fistula  is  deep  in  the  pelvis,  it  is  better  to  pass  the  gauze  drain  into 
the  vagina  through  an  opening  made  for  the  purpose  and  to  close  the 
abdominal  wound. 

4.  If  the  fistula  is  too  large  for  suture,  the  parietal  peritoneum 
may  be  made  to  take  the  pla'ce  of  the  lost  intestinal  wall.  This  will 
require  the  edges  of  the  fistula  to  be  united  to  the  abdominal  wall  by 
means  of  a  plate  of  decalcified  bone  or  other  absorbable  material. 
The  plate  should  have  small  perforations  one-sixth  of  an  inch  apart 
all  around  near  its  outer  edge ;  it  is  placed  inside  the  intestinal 
opening,  and  through  this  perforation  tlie  margin  of  the  bowel  may  be 
stitched  to  the  parietal  peritoneum .  The  sutures  should  transfix  the 
bowel- wall  and  the"  abdominal  wall  and  be  tied  on  the  skin,  thereby 
approximating  serosa  to  serosa. 

The  following  case  is  illustrative  and  instructive.  In  an  operation 
at  St.  Luke's  Hospital,  Chicago,  a  large  friable  pus-tube  was  in  com- 
munication with  the  bowel  at  two  points.  After  enucleation  there  was 
a  fistula  too  large  to  be  closed  at  each  of  these  points.  The  bowel- 
wall  surrounding  the  fistula  was,  moreover,  extremely  thickened  and 
friable.  The  first  impulse  was  to  resect  the  bowel  at  each  point  of 
injury.  Instead  of  this  most  formidable  operation,  however,  the  fol- 
lowing plan  ^vas  adopted  successfully  :  The  two  openings  were  brought 
together  and  united  by  three  rows  of  fine  continuous  silk  sutures,  the 
fistulee  thereby  being  utilized  as  openmgs  for  an  intestmal  anastomosis. 
The  abdominal  wound  w.as  closed  with  only  a  slight  gauze  drain  ex- 
tending from  its  upper  angle  to  the  immediate  neighborhood  of  the 
intestinal  sutures.  This  drain  was  removed  on  the  fourth  day.  The 
result  was  complete  recovery.  .  So  far  as  the  writer  is  informed,  this 
principle  has  never  been  used  in  a  case  like  the  above. 

Technique  iu  Accidental  Woimds  of  tlie  Ureter. — In  the  course  of  a 
pelvic  operation  the  ureter  may  be  cut  accidentally  in  the  longitudinal 
direction,  or  partially  severed  in  the  transverse  direction,  or  completely 
divided.     Then  one  of  the  following  operations  will  be  indicated  : 

Foe  Incomplete  Division  of  the  Ureter. 

Ureterorrhapliy. — If  a  ureter  opened  in  the  longitudinal  direction  is 
closed  by  a  line  of  union  running  in  the  same  direction,  there,  will  be 
danger  of  stricture  at  the  point  of  closure.  To  jsrevent  this,  the  line 
of  union  should  run  at  right  angles  to  the  line  of  incision — that  is, 
transversely,  as  suggested  by  Fenger,  who  deliberately  opened  a  stric- 
tured  ureter  longitudinally  and  then  increased  the  calibre  by  closing 
it  transverselv. 


SURGICAL   TREATMENT  OF  SALPINGITIS.  299 

In  case  of  partial  transverse  division,  Van  Hook  suggests  that  a 
longitudinal  incision  be  made  directly  across  the  middle  of  the  trans- 
verse cut  at  right  angles  to  it  and  twice  as  long  as  the  diameter  of  the 
tube.  The  sharp  angles  should  then  be  rounded  off  ^vith  scissors  and 
the  wound  sutured,  as  described  above  for  longitudinal  ^\ounds. 

For  Complete  Drvisiox  of  the  Ureter. 

Insertion  into  the  Bladder. — If  the  part  above  the  injury  can  be 
drawn  down  to  the  bladder  without  undue  traction,  it  should  be 
inserted  into  the  bladder  through  an  opening  made  for  the  purpose 
and  fixed  there  by  means  of  fine  sutures. 

Lateral  Anastomosis. — If  the  part  above  the  injury  will  not  reach 
the  bladder,  it  may  be  inserted  into  the  lower  fragment  after  the 
method  of  Van  Hook.     This  operation  is  shown  in  Figure  130. 

FiGUBE  130. 


Lateral  anastomosis  of  the  ureter. 

A.  First  step :  natural  size.  Showing  the  fragment  toward  the  bladder  tied  and  slit  longi- 
tudinally for  the  reception  of  the  upper  fragment.  The  two  ends  of  a  fine  silk  or  chromic  cat- 
gut suture  have  been  passed  through  the  ureteral  wall  near  the  end  of  the  upper  fragment  from 
within  outward.  Two  tine  needles  on  this  suture  are  transfixing  the  wall  of  the  lower  fragment 
preparatory  to  drawing  the  end  of  the  upper  fragment  into  the  longitudinal  slit. 

B.  Second  step  :  natural  size.  The  upper  fragment  has  been  drawn  into  the  longitudinal 
slit  in  the  lower  fragment  and  made  fast  by  tying  the  suture  :  in  order  to  insure  security  against 
leakage,  one  more  similar  suture  should  be  placed  and  tied  on  the  opposite  side,  and  a  few  very 
fine  interrupted  sutures  should  be  introduced  quite  superficially  around  the  anastomotic 
union.  The  anastomosis  thus  completed  should  be  covered  by  stitching  omentum  or  some 
other  peritoneal  structure  over  it.  If  there  is  no  apparent  leakage,  the  abdominal  wound  may- 
be closed  without  drain. 

Ureteral  Fistula  to  the  External  Surface. — If  for  any  reason  none 
of  the  above  operations  is  practical,  the  ureter  should  be  brought  out 
through  the  lower  end  of  the  abdominal  wound  at  the  nearest  possible 
point  to  the  bladder,  so  that  the  urine  may  discharge  temporarily  to 
tlie  external  surface  until  connection  with  the  bladder  can  be  attempted, 
for  example,  as  follows  : 

Ureterocystostomy  by  Bladder  Diverticulum. — For  cases  in  which 
the  ureter  cannot  be  made  to  reach  the  bladder,  A^an  Hook  proposes 
that  the  bladder  be  extended  to  the  ureter  by  dissecting  a  flap  from 
the  anterior  vesical  wall  and  reflecting  it  upward  to  meet  the  ureter 
in  such  a  manner  as  to  form  a  tubular  diverticulum  from  the  bladder 
to  the  ureter. 

Nephrectomy. — When  the  ureter  cannot  be  connected  with  the 
bladder,  the  only  alternative  may  be  to  remove  the  kidney  on  the 
affected  side. 

Operation  by  Vaginal  Section. 

The  maxim  that  every  peritoneal  section  should  begin  as  an  ex- 
ploration holds  ^rue   us  well  for  vaginal  as  for  abdominal  section. 


300    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Thorough  sharp  curettage  and  cleansing  of  the  endometrium  are 
essential  preliminaries.  The  object  is,  first,  to  remove  the  original 
source  of  infection ;  second,  to  prevent  infection  of  the  peritoneum 
from  the  uterus  during  the  operation.  Vaginal  section  according  to 
the  indication  is  made  either  anterior  or  posterior  to  the  uterus,  or 
both  anteriorly  and  posteriorly. 

Posterior  Vaginal  Section. — The  posterior  incision  is  made  close 
to  the  uterus,  between  the  cervix  uteri  and  the  rectum,  from  the  post- 
vaginal  fornix  into  the  pouch  of  Douglas.  The  steps  of  the  operation 
are  as  follows : 

1.  The  patient  is  to  be  placed  in  the  dorsal  position  and  the  vag- 
inal portion  of  the  cervix  exposed  by  Simon's  retractors. 

2.  A  semicircular  incision,  large  enough  to  admit  two  fingers,  is 
made  directly  behind  the  uterus  in  the  line  of  the  uterovaginal 
attachment,  with  blunt-pointed  scissors  curved  on  the  flat,  the  point 
being  directed  toward  the  uterus  and  the  cervix  being  drawn  down 
by  the  vulsellum  forceps. 

3.  The  loose  cellular  tissue  back  of  the  cervix  between  the  vagina 
and  the  pouch  of  Douglas  is  stripped  back  off  from  the  cervix  by 
the  blunt  point  of  the  scissors,  by  the  handle  of  a  scalpel,  or  by  the 
finger,  until  the  peritoneum  is  reached. 

4.  The  peritoneum  is  divided  close  to  the  uterus  by  a  snip  of  the 
scissors.  The  closed  scissors-points  are  now  passed  through  into  the 
pouch  of  Douglas  and  the  opening  is  dilated  by  spreading  the  blades, 
and  if  necessary  enlarged  still  further  by  careful  cutting  with  the 
scissors  or  by  tearing  with  the  fingers. 

5.  The  index  and  middle  fingers  of  the  left  hand  now  are  intro- 
duced into  the  pouch  of  Douglas  and  the  pelvic  cavity  is  explored 
digitally.  If  sufficient  room  has  not  been  gained,  a  perpendicular 
incision,  beginning  in  the  middle  of  the  posterior  border  of  the  one 
already  described  and  running  toward  the  rectum,  may  be  made. 
In  cutting  down  toward  the  bowel  the  left  index-finger  in  the 
rectum  should  be  used  as  a  guide.  This  finger  then  is  withdrawn, 
disinfected,  and  with  a  fresh  rubber  glove  reintroduced  into  the  pouch 
of  Douglas ;  the  right  hand  is  placed  over  the  hypogastrium  behind 
the  pubes,  and  the  examination  is  made  precisely  as  in  ordinary 
bimanual  palpation,  but  with  a  distinct  advantage — i.  e.,  the  palpat- 
ing finger  is  in  direct  contact  with  the  uterus  and  its  appendages. 

Posterior  vaginal  section  is  not  well  adapted  to  removal  of  the 
appendages  ;  it  is,  however,  specially  applicable  to  the  incision  and 
drainage  of  pelvic  pus-cavities.  These  cavities  may  be  in  the  tubes, 
ovaries,  or  pelvic  connective  tissue.  See  Incision  and  Drainage  of 
Pelvic  Abscesses. 

Anterior  Vaginal  Section. — Peritoneal  section  anterior  to  the 
uterus — i.  e.,  between  the  uterus  and  bladder — renders  the  uterus  and 
its  appendages  more  accessible  to  conservative  radical  operation  than 
posterior  section,  but  less  accessible  than  abdominal  section.  The 
technique  is  similar  to  that  of  posterior  section,  and  is  as  follows  : 

The  patient  is  placed  in  the  dorsal  position  and  the  cervix  exposed 
by  Simon's  retractors.     The  cervix  is  seized  with  vulsellum  forceps 


SURGICAL   TREATMENT  OF  SALPINGITIS. 


301 


and  drawn  toward  the  vulva.  A  transverse  semicircular  incision 
close  to  the  uterus,  in  a  line  with  the  uterovaginal  attachment,  is 
made  with  scissors  through  the  anterior  vaginal  fornix  ;  or,  instead 
of  this,  the  incision  is  made  in  the  longitudinal  direction  in  the 
median  line  through  the  anterior  vaginal  wall  from  the  anterior  wall 
of  the  cervix  toward  the  bladder.  The  latter  incision  is  preferable, 
because,  without  great  care,  especially  if  the  cervix  is  small,  the  trans- 
verse incision  is  liable  to  injure  the  ureters.  In  making  the  longi- 
tudinal incision,  the  operator  should  not  only  draw  the  cervix  uteri 
well  down,  but  also  make  strong  downward  traction  on  the  anterior 

FiGUBE  131. 


'.A 


L 


Lines  of  anterior,  posterior,  and  lateral  incisions  in  vaginal  section :  A,  anterior  incision ; 
P,  posterior  incision  ;  L,  L,  lateral  incisions. 

vaginal  wall.  This  is  done  with  a  tooth-forceps  attached  to  the  Avail 
between  the  cervix  uteri  and  the  urethra.  If  the  longitudinal  inci- 
sion give  insufficient  room,  it  may  be  supplemented  by  the  transverse. 
The  combined  longitudinal  and  transverse  cuts  have  the  shape  of  the 
letter  T.  They  are  shown  in  Figure  131,  and  in  the  surgical  treat- 
ment of  myomata.  Chapter  XXYII. 

The  uterus  now  is  drawn  strongly  forward,  and  the  structures 
adjacent  to  its  anterior  wall  are  stripped  off,  keeping  close  to  the 
uterus,  as  described  above  for  posterior  section.  As  the  bladder  is 
being  separated  from  the  uterus  it  is  held  up  out  of  the  way  by  an 
anterior  retractor  or  the  finger.     When  the  peritoneum  comes  into 


302    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

view,  it  will  be  recognized  as  a  thin,  translucent  membrane  reflected 
from  the  uterus.  A  sound  passed  into  the  bladder  will  prevent  cut- 
ting that  organ  for  the  peritoneum.  The  peritoneum  is  snipped  with 
blunt-pointed  scissors.  The  opening  thus  made  into  the  pelvic 
cavity  is  enlarged  by  introducing  the  two  index-fingers  and  tearing 
laterally,  and,  if  necessary,  by  careful  cutting  with  the  scissors.  Dur- 
ing the  separation  of  the  bladder  from  the  uterus  a  sound  in  the  uterine 
canal  may  be  useful  as  a  guide. 

The  corpus  uteri  may  now,  if  adhesions  do  not  prevent,  be  seized 
with  vulsellum  or  bullet-forceps  and  the  fundus  drawn  into  the 
vagina.  If  there  be  adhesions,  they  may  be  loosened  with  the  left 
index-finger  introduced  over  the  fundus  uteri,  the  corpus  being  at 
the  same  time  drawn  more  and  more  into  the  vaginal  opening.  The 
Fallopian  tubes  and  ovaries  follow  the  corpus,  and  may  be  subjected 
to  examination  and  any  necessary  operation.  They  may  be  removed 
wholly  or  partially  as  in  abdominal  section.  The  closed  fimbriated 
extremity  of  a  tube  may  be  opened  or  the  ovary  may  be  resected.  See 
Conservative  Operative  Treatment  of  Adnexal  Inflammation  at  the 
end  of  this  chapter. 

The  removal  of  the  appendages  by  anterior  vaginal  section  does 
not  materially  diifer  in  technique  from  removal  by  abdominal  section. 
Haemostasis  may  be  secured  by  the  usual  ligature  close  to  the  uterus 
or  by  running  sutures  in  the  broad  ligament.  To  bring  the  append- 
ages into  full  view  may  require  firm  traction,  and  the  uterus  may  have 
to  be  drawn  from  side  to  side.  Ligation  of  the  infundibulopelvic 
ligament,  which  controls  the  ovarian  vessels,  is  often  difficult,  some- 
times impossible.  Sometimes  the  broad  ligament,  if  short,  tense,  and 
adherent,  cannot  be  reached  through  the  vagina.  In  such  case  it 
would  be  safer  to  abandon  the  vaginal  and  resort  to  the  abdominal 
route.  If  there  is  difficulty  in  returning  the  uterus,  enlarged  by  con- 
gestion, from  torsion  of  the  ligaments,  the  Simon  retractor  may  be 
used  in  the  manner  of  a  shoe-horn,  and  the  uterus  slid  in  on  the 
smooth  blade. 

The  blood-clots  having  been  sponged  out  and  all  bleeding  points 
secured,  the  wound  is  closed  as  follows  :  The  peritoneal  margins  are 
drawn  down  and  approximated  by  means  of  pressure-forceps.  They 
then  are  whipped  together  with  a  running  fine  catgut  suture.  The 
suture  is  continued  as  a  buried  suture  to  unite  the  vesical  to  the 
uterine  surfaces  of  the  wound,  and  finally,  as  a  running  suture  to  close 
the  vaginal  margins.     The  vagina  is  packed  lightly  with  aseptic  gauze. 

The  anterior  incision,  except  for  drainage  of  pus-cavities,  is  prefer- 
able to  the  posterior.  It  involves  less  danger  of  post-uterine  ad- 
hesions, which  may  result  in  fixation  of  the  retro  verted  or  retroflexed 
uterus.  Moreover,  it  offers  by  anterior  vaginal  fixation  a  cure  for 
the  retromalpositions.  See  Treatment  of  Retroversion  and  Retro- 
flexion by  Vaginal  Fixation,  Chapter  XLVII.  In  some  cases  intra- 
pelvic  disease  is  rendered  more  accessible  by  the  combined  anterior 
and  posterior  incisions. 

Effects  of  Removal  of  the  Uterine  Appendag-es. — Removal  of 
the  ovaries  and  Fallopian  tubes  has  been  usual  in  hydrosalpinx,  and 


SURGICAL   TREATMENT  OF  SALPINGITIS.  303 

is  the  rule  in  pyosalpinx.  The  operation,  if  thoroughly  performed, 
is  followed  generally  by  atrophy  and  consequent  arrest  of  function 
in  the  uterus,  and  the  precipitation  of  the  menopause.  The  arti- 
ficial production  of  this  critical  period  gives  rise  to  phenomena  quite 
similar  to  those  which  characterize  the  natural  menopause,  except  in 
most  cases  menstruation  is  arrested  permanently  at  once.  The  popu- 
lar impression  that  the  operation  unsexes  the  woman  in  a  mental  sense 
or  renders  her  masculine  is  a  mistake.  Patients  frequently  ask 
whether  it  will  result  in  the  growing  of  a  beard  or  the  development 
of  a  bass  voice  ;  but  no  such  result  has  ever  been  observed.  The  ope- 
ration performed  on  a  young  girl  would  doul)tless  arrest  the  intra- 
pelvic  and  some  of  the  extrapelvic  developmental  processes  of  puberty, 
but  development  once  made  is  permanent. 

The  effect  of  the  operation  upon  sexual  desire  is  variable,  but 
probably  no  more  so  than  that  of  the  natural  menopause. 

The  question  of  insanity  as  a  result  of  the  operation  has  been 
raised;  it  probably  occurs  no  more  frequently  than  after  other  opera- 
tions of  equal  gravity,  probably  not  oftener  than  with  the  natural 
menopause. 

The  primary  object  of  the  operation  is  the  removal  of  certain 
organs  which  otherwise  would  be  dangerous  to  life  or  destructive  to 
health.-  A  most  important  secondary  result  is  the  arrest  of  physio- 
logical function  in  the  remaining  uterus.  In  this  connection  it  is 
clear  that,  since  pathology  is  physiology  modified  by  disease,  the 
atrophic  ■  changes  in  the  uterus  consequent  upon  the  operation  may, 
at  the  same  time  that  they  arrest  physiological  processes,  also  put  an 
end  to  pathological  processes.  Especially  is  this  true  in  the  inflamed 
uterus,  disease  of  which  often  is  perpetuated  by  the  constantly  recur- 
ring menstruation.  The  frequent  disappearance  of  metritis  from  the 
atrophic  uterus  verifies  a  recognized  principle  that  physiological  rest 
may  favor  the  cure  of  disease. .  If  the  uterus  is  healthy  or  the  seat 
of  only  mild  catarrhal  inflammation,  it  usually,  upon  the  removal  of 
the  appendages,  will  pass  rapidly  into  the  atrophic  state,  and  give  no 
more  trouble  than  would  a  uterus  after  the  usual  menopause.  Unfor- 
tunately, however,  this  very  common  sequence  of  the  removal  of  the 
appendages  is  not  constant.  The  atrophic  process  does  not  always 
follow,  or,  if  it  follows,  may  fail  to  remove  the  infection.  The  in- 
fected uterus  may  be  the  source  of  pernicious  menstruation,  amount- 
ing at  times  to  hemorrhage.  A  surviving  and  intractable  endometritis 
often  gives  rise  to  profuse  uterine  discharges.  Exhaustive  drains 
upon  the  patient's  strength  from  such  cause  may  destroy  her  resistance 
to  disease,  reinforce  the  uterine  infection,  and  perpetuate  a  group  of 
disabling  nervous  symptoms. 

Should  the  Uterus  be  Removed  with  the  Appendages  ? — This 
question  has  been  forced  upon  the  surgeon  Ijy  the  numerous  immedi- 
ate and  remote  failures  which  have  followed  removal  of  the  append- 
ages alone.  When  the  appendages  on  one  side  are  healthy,  or  not 
sufficiently  diseased  to  necessitate  their  removal,  and  when  enough 
ovarian  tissue  can  be  left  to  give  hope  that  the  reproductive  func- 
tion may  be  preserved,  the  answer  is  negative.     The  essential  ques- 


304    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDEBS. 

tion  is,  What  shall  be  done  with  the  uterus  when  the  appendages  on 
both  sides  have  to  be  removed  completely  ?  It  may  be  urged  with  con- 
siderable force  that  failure  to  bring  about  atrophy  of  the  uterus,  arrest 
function,  and  to  secure  consequent  relief  from  pernicious  symptoms, 
arises  in  many  cases  from  faulty  technique  in  the  operation.  Arthur 
W.  Johnstone  and  Lawson  Tai't  have  shown  that  when  the  tubes  are 
taken  off  close  to  the  uterus  and  every  particle  of  the  appendages 
removed,  arrest  of  menstruation,  atrophy  of  the  uterus,  and  a  satis- 
factory menopause,  even  in  cases  of  infected  uteri,  are  apt  to  follow. 
The  explanation  of  this  is  simple  and  as  follows  :  The  thorough 
removal  of  the  tubes  cuts  off  the  ovarian  artery  and  the  supply  from 
the  uterine  artery  at  the  point  of  anastomosis  with  the  ovarian.  As 
pointed  out  by  Johnstone,  it  also  cuts  in  a  similar  way  the  nerve  con- 
nections of  the  uterus  ;  hence  the  observed  atrophy  and  arrest  of 
function.  The  claim  of  the  enthusiastic  hysterectomist,  that  when  the 
appendages  have  been  sacrificed  the  uterus  necessarily  becomes  a  per- 
nicious, continuous,  disabling,  and  dangerous  source  of  infection,  may, 
as  a  universal  proposition,  be  disregarded.  In  order  to  bring  about 
the  most  satisfactory  results  the  tubes  should  be  removed  not  merely 
close  to  the  uterus,  but  the  entire  tubes,  even  as  they  penetrate  the 
cornua,  should  be  removed  to  the  uterine  mucosa,  and  the  cornual 
wounds  should  be  closed  by  catgut  sutures  ;  the  removal  of  a  tube  by 
the  ordinary  stump  and  ligature  method  which  may  result  in  leakage 
of  uterine  secretions  into  the  pelvic  cavity,  properly  has  been  aban- 
doned. In  thus  emphasizing  the  necessity  of  complete  removal  of  the 
tubes  we  should  have  clearly  in  mind  not  only  arrest  of  menstruation 
but  also  avoidance  of  stump  exudation  already  mentioned  on  a  pre- 
vious page. 

The  propriety  of  leaving  an  infected  uterus  while  the  causative 
infection  in  the  endometrium  is  still  overwhelming  the  pelvic  lym- 
phatics with  its  septic  supply  is  indeed  questionable ;  for  the  uterine 
infection  may  continue  to  spread  to  the  peritoneum  even  after  removal 
of  the  appendages.  If  vaginal  incision  and  drainage  are  deemed  inad- 
equate, the  removal  of  the  uterus,  together  with  the  appendages,  may 
be  necessary  for  two  reasons  :  first,  to  cut  off  the  septic  supply  ;  second, 
to  facilitate  drainage. 

If  in  consequence  of  great  infection  it  becomes  necessary  to  remove 
the  uterus,  the  surgeon  should  avoid  the  half-way  measure  of  removing 
only  the  corpus,  for  if  the  cervix  he  left,  it  may  continue  to  he  the  source 
of  persistent  and  pernicious  infection  in  the  adjacent  structures,  even  to 
the  extent  of  filling  the  pelvis  loith  stump  exudate.  In  fact,  to  remove  the 
corpus  and  leave  an  infected  cervix  would  be  inexcusable,  for  the  cervi- 
cal glands,  as  pointed  out  in  the  Chapter  on  Endometritis,  are  specially 
adapted  to  the  reception,  the  retention,  and  the  distribution  of  infection. 

The  Objections  to  Hysterectomy  are  as  follows : 

1.  The  fact  that  the  uterus  is  an  important  part  of  the  pelvic  floor 
and  is  necessary  therefore  to  the  integrity  of  the  pelvic  diaphragm. 

2.  The  possibility  that  removal  of  the  uterus,  in  addition  to  re- 
moval of  the  appendages,  may  disturb  the  moral  and  physical  well-being 
of  the  woman  to  a  greater  extent  than  removal  of  the  appendages 
alone.     However  this  may  be,  since  many  women  have  the  strongest 


SURGICAL  TREATMENT  OF  SALPINGITIS'.  305 

aversion    to  hysterectomy,  their  wishes  so  far  as  may  be,  without 
harm,  should  be  respected. 

3.  The  fact  that  removal  of  the  uterus,  especially  by  a  slow  or 
inexpert  operator,  involves  additional  shock  and  danger. 

4.  The  possibility  that  hysterectomy  may  cause  secondary  degenera- 
tive changes  in  the  spinal  cord  or  brain.  This  possible  result  has 
been  observed  as  a  sequel  of  major  operations  in  other  parts,  especially 
those  involving  extensive  injury  to  nerve  structures. 

5.  The  possibility  that  the  uterus,  like  the  ovary,  may  have  an 
important  function  as  an  eliminative  organ. 

6.  The  absence  of  a  clear  indication. 

SURGICAL  TREATMENT  OF  SALPINGITIS. 

The  Indications  for  Hysterectomy  are  as  follows : 

1.  The  matting  together  of  the  reproductive  organs  in  one  infected 
mass,  with  pockets  of  pus.  The  difficulty  of  operation  does  not  neces- 
sarily neutralize  this  indication. 

2.  Tuberculosis  of  the  reproductive  organs. 

3.  Complicating  malignant  disease. 

4.  Complicating  uterine  myoma,  which  cannot  be  removed  without 
sacrificing  the  uterus. 

5.  Involvement  of  the  endometrium  in  destructive  inflammation, 
so  that  the  uterine  wall,  itself  strongly  infected,  becomes  virtually  the 
wall  of  a  pus-cavity ;  under  these  conditions  the  uterus  is  decidedly  a 
source  of  danger. 

The  value  of  the  uterus  as  an  essential  part  of  the  pelvic  floor  has 
led  some  operators  to  remove  the  corpus  and  leave  the  cervix,  or  at 
least  the  vaginal  portion  of  it.  This  is  practical  only  when  the  opera- 
tion is  performed  by  the  abdominal  route,  a  route  which  contemplated 
originally  but  one  wound,  and  that  through  the  abdomen.  To  leave 
the  cervix,  therefore,  after  removal  of  the  corpus,  is  a  natural  corollary 
of  the  abdominal  operation.  If  hysterectomy,  on  account  of  the  infec- 
tious character  of  the  uterus,  is  to  be  performed,  the  operation  should 
include  at  least  that  part  which  is  usually  most  infected  and,  therefore, 
most  pernicious — the  cervix.  The  idea  of  leaving  it  hardly  would 
occur  in  connection  with  the  vaginal  operation. 

Vaginal  Hysterectomy. 

Abdominal  hysterectomy  for  pelvic  infection,  in  the  author's  judg- 
ment, is  much  more  frequently  the  operation  of  choice  than  vaginal  hys- 
terectomy. The  vaginal  operation,  however,  has  recognition  in  the  surgery 
of  infectious  arid  malignant  disease  of  the  uterus  and  of  complete  descent 
of  the  uterus;  for  this  reason  it  is  here  described  fully,  ivith  extended 
illustrations.  Reference  to  the  operation  will  be  made  in  follounng  chap- 
ters on  other  subjects,  as  the  occasion  may  arise. 

In  the  vaginal  operation  for  the  removal  of  the  uterus  two  princi- 
pal methods  of  hsemostasis  are  in  use  : 

Hfemostasis  by  ligature. 

Haemostasis  by  forcipressure. 
^0 


306   INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS. 

Vaginal  Hysterectomy  with  Haemostasis  by  Ligature. — The 

technique  of  the  operation  is  as  follows:  The  patient  is  placed  in  the 
lithotomy  position ;  the  vulvo-vaginal  surfaces  are  thoroughly  disin- 
fected— Cliapter  IL;  the  cervical  canal  is  dilated  ;  and  the  endome- 
trium curetted,  washed  out,  and  disinfected  with  formalin  and  iodine — 
Chapter  XVII.  Some  operators  close  the  os  externum  with  tempo- 
rary suture  to  prevent  escape  of  uterine  secretions  during  the  opera- 
tion. The  cervix  uteri  is  brought  into  view  by  means  of  one  or  two 
Simon  retractors,  seized  with  strong  vulsellum  forceps,  and  drawn 
toward  the  vulva.  A  free  incision  with  scissors  is  made  all  around 
the  cervix.  The  loose  tissues  around  the  cervix  are  stripped  back 
easily  by  means  of  the  finger  or  handle  of  the  scalpel,  keeping  as 
close  to  the  uterus  as  the  disease  will  permit.  Small  bleeding  points 
are  controlled  by  catgut  ligatures.  In  this  way  the  circumuterine 
structures  may  be  stripped  back  from  the  uterus  until  the  exposed 
part  of  the  cervix  is  measured  by  a  zone  three-quarters  of  an  inch  or 
more  wide.  This  zone  extends  anteriorly  and  posteriorly  to  the  ante- 
rior and  posterior  uteroperitoneal  reflections,  and  laterally  to  the  broad 
ligaments.  The  uterus  can  now  be  drawn  down  much  lower,  and, 
with  the  bladder  thus  separated  from  the  uterus,  the  ureters,  which 
lie  close  to  the  uterus,  can  be  avoided  easily.  The  post-cervical  struc- 
tures now  are  separated  further  by  means  of  the  finger  or  the  handle 
of  the  scalpel,  or  the  closed  blunt  scissors,  until  the  cul-de-sac  of 
Douglas  is  opened.  This  opening  is  enlarged  easily  by  introducing 
the  two  index-fingers  and  tearing  laterally  to  the  region  of  the  broad 
ligaments.  A  large  gauze  sponge,  with  a  string  attached  to  facilitate 
removal,  now  is  forced  through  into  the  cul-de-sac  of  Douglas.  This 
will  protect  the  pelvic  viscera  and  absorb  blood  during  the  remainder 
of  the  operation. 

A  like  opening  anterior  to  the  uterus  between  the  uterus  and 
bladder  is  made  also  into  the  peritoneal  cavity.  As  was  done  pos- 
teriorly, this  opening  is  enlarged  to  the  region  of  the  broad  ligaments 
by  lateral  tearing  with  the  index-fingers,  and  the  peritoneal  edge  of 
each  opening,  if  the  operator  so  elect,  may  be  stitched  to  the  vaginal 
edge.  The  whip-stitch  by  which  this  is  done  anteriorly  and  posteriorly 
reduces  the  size  of  the  wound,  prevents  bleeding,  and  thereby  simpli- 
fies the  operation.  The  anterior  opening  sometimes  may  be  made 
more  easily  by  passing  the  index-finger  through  the  posterior  opening, 
and,  if  possible,  hooking  it  over  the  broad  ligament,  so  that  it  may 
serve  in  some  degree  as  a  guide,  and  thereby  prevent  the  operator 
from  wounding  the  bladder,  ureters,  or  anterior  uterine  wall.  Then 
the  index-finger  of  the  left  hand  or  a  blunt  hook  is  hooked  over  the 
left  broad  ligament,  the  ligament  is  drawn  down  and  transfixed,  and 
tied  en  masse,  or,  if  very  large,  in  sections.  The  application  of  the 
ligatures  may  be  facilitated  by  anteverting  the  uterus  and  drawing  the 
corpus  through  the  anterior  opening  by  means  of  vulsellum  forceps. 
This  twists  the  ligaments  upon  themselves,  makes  them  smaller,  and 
brings  their  upper  margins  within  reach.  Separate  ligatures  usually 
are  needed  for  the  uterine  appendages.     Figures   132   to  137   will 


SURGICAL   TREATMENT  OF  SALPINGITIS.  307 

show  the  technique  of  the  operation.  Each  ligament  usually  is 
ligatured  in  two  or  three  sections.  The  ligatures — preferably  catgut 
— are  passed  by  means  of  aneurism-needles,  or  with  the  ordinary 
threaded  needle  and  forceps.  In  some  cases  an  entire  ligament  may 
be  secured  by  a  single  ligature,  but  more  frequently  portions  of  it  on 
either  side  are  tied  progressively  and  cut  away  from  the  uterus  until 
the  organ  finally  is  removed.  In  many  cases  hysterectomy  is  facili- 
tated by  dividing  the  uterus  into  halves.  Each  half  may  then  be 
drawn  through  the  vagina  separately  and  removed.  The  ends  of  the 
ligatures,  having  been  left  long,  are  used  now  to  draw  the  stumps 
down  into  the  vaginal  wound,  where  they  are  treated  as  shown  in 
Figure  137.  If  the  stumps  will  not  reach  to  the  vagina,  the  ligatures 
are  cut  short,  and  the  stumps  returned  to  the  pelvic  cavity.  Some- 
times all  the  stumps  are  too  short,  and  therefore  must  be  treated 
intraperitoneally.  The  vaginal  wound  will  then  be  closed  as  the  con- 
ditions may  require,  with  or  without  the  gauze  drain.  See  Chapter 
VII.,  on  Drainage. 

Vaginal  Hysterectomy  with  Haemostasis  by  Forcipressure. — 
Hsemostasis  by  forcipressure  is  the  same  in  general  technique  as  that 
by  ligature  except  the  use  of  forceps  in  place  of  the  ligature.  After  the 
openings  anterior  and  posterior  to  the  uterus  have  been  made  the  liga- 
ment is  drawn  down  and  seized  with  haemostatic  forceps,  the  grasp  being 
at  a  sufficient  distance  from  the  uterus  to  prevent  the  instruments  from 
slipping  off  after  the  organ  has  been  severed.  These  forceps  are  con- 
structed on  the  principle  of  Pean,  but  should  be  heavier  and  with 
jaws  about  two  inches  long.  Various  broad  ligament  clamps  have 
been  devised,  but  none  fulfils  the  indication  better  than  the  straight, 
strong  haemostatic  forceps.  The  forceps  handles  are  locked  securely, 
the  ligament  is  severed  close  to  the  uterus,  and  the  whole  uterus 
pulled  outside.  The  organ  now  hangs  by  the  other  broad  ligament. 
This  in  turn  is  clamped  in  the  same  way,  and  the  uterus  is  removed 
by  a  few  strokes  of  the  scissors.  The  ovaries  and  Fallopian  tubes, 
unless  already  included  with  the  broad  ligaments,  may  be  secured  by 
separate  forceps.  If,  upon  examination,  the  operator  fears  that  the 
broad  ligament  is  diseased  beyond  the  grasp  of  the  first  forceps,  he  may 
put  on  other  forceps  back  of  those  first  applied.  The  first  forceps  may 
then  be  removed  and  the  diseased  tissues  cut  away.  Fatal  hemor- 
rhage has  resulted  from  slipping  of  the  broad  ligament  forceps ; 
hence  the  necessity  of  so  making  the  incision  through  the  ligament  as 
to  leave  considerable  tissue  on  the  distal  side  of  their  jaws.  To  j)re- 
vent  the  forceps  handles  f7-om  snapping  apart,  they  should  be  tied  tog  ether 
securely  ivith  strong  thread. 

In  many  cases  the  uterus  is  much  enlarged,  and  the  ligaments 
therefore  on  either  side  extend  so  high  in  the  pelvis  that  they  cannot 
be  drawn  down  within  the  grasp  of  a  single  pair  of  forceps.  Then 
one  pair  of  forceps  may  be  put  on,  and  that  part  of  the  ligament 
which  is  in  their  grasp  divided.  The  uterus  can  then  be  drawn  further 
down,  and  the  remaining  portion  of  the  ligament,  having  been 
clamped  by  one  or  more  forceps,  may  be  severed.     If  so  much  space 


Explanation  of  Figure  132. 

A.  Vaginal  hysterectomy.     The  patient  in  the  dorsal  position. 

The  vagma  and  cervix  uteri  are  exposed  by  retractoi"s  in  the  hands  of  assistants. 

The  OS  uteri  externum  has  been  closed  by  a  continuous  suture,  to  protect  the 
operation  wound  and  the  peritoneum  from  the  uterine  secretions. 

The  cervix  uteri  has  been  seized  by  strong  fliat  vulsellum  fore  eps  in  the  left  hand 
of  the  operator  and  drawn  strongly  down  toward  the  vulva. 

The  opei"ator,  with  scissors  in  his  right  hand,  is  making  a  free  incision  through  the 
mucosa  all  around  the  cervix  uteri  in  the  line  of  the  utero-vaginal  attachment.  The 
black  and  white  dotted  lines  indicate  the  direction  of  the  incision. 

The  bleeding  points  are  secured  by  fine  catgut  ligatures — not  shown. 
'  B.  The  mucosa  all  around  the  uterus  has  been  divided  by  scissoi's.  While  strong 
traction  is  being  made  on  the  uterus  by  the  forceps  in  the  right  hand  of  the  operator, 
the  left  index  finger  is  used  to  strip  back  the  circumuterine  tissue  all  around  the 
cervix.  The  stripping  process  is  continued  until  it  has  exposed  a  zone  of  raw  tissue 
an  inch  or  more  wide,  when  the  utero-peritoneal  reflexion  will  be  recognized  by  the 
loose,  thin,  membranous  character  of  the  tissue,  and  by  the  fact  that  under  the  finger 
it  slips  over  the  adjacent  peritoneal  covering  of  the  uterus. 
308 


Figure  132 


309 


Figure  133 


310 


Explanation  of  Figure  133. 

Vaginal  hysterectomy.     The  patient  is  in  the  dorsal  position. 

The  vagina  and  cervix  uteri  are  exposed  by  retractors  in  the  hands  of  assistants. 

The  OS  uteri  externum  has  been  closed  by  a  continuous  suture  to  protect  the 
operation  wound  and  the  peritoneum  from  uterine  secretions. 

The  cervix  uteri  has  been  seized  by  strong  flat  vulsellum  forceps  in  the  left  hand 
of  the  operator  and  di-awn  strongly  down  toward  the  vulva. 

A.  The  circumuterine  structures  have  been  stripped  down  to  the  utero-peritoneal 
fold,  as  shown  in  Figure  132  ;  the  operator  seizes  this  fold  posterior  to  the  uterus  with 
a  hjemostatic  forceps  in  the  left  hand,  and  with  scissors  in  the  right  hand  cuts  thi-ough 
into  the  cul-de-sac  of  Douglas. 

B.  The  operator,  with  the  index  fingei-s  inserted  into  the  cul-de-sac  of  Douglas 
through  the  opening  shown  in  A,  is  tearing  latei-ally  to  the  region  of  the  broad 
ligaments. 

A  similar  incision  is  then  made  into  the  pelvic  cavity  anterior  to  the  uterus,  and 
enlarged  by  lateral  tearing  to  the  region  of  the  broad  ligaments  in  the  manner 
described  above,  so  that  the  uterus  is  attached  to  its  surroundings  by  only  the  broad 
ligaments. 

311 


Explanation  of  Figure  134. 

Vaginal  Hysterectomy.     The  patient  is  in  the  dorsal  position. 

The  vagina  and  cervix  uteri  are  exposed  by  retractors  in  the  hands  of  assistants. 

The  OS  uteri  externum  has  been  closed  by  a  continuous  suture  to  protect  the  opera- 
tion wound  and  the  peritoneum  from  the  uterine  secretions. 

The  cervix  uteri  has  been  seized  by  strong  flat  vulsellum  forceps  in  the  left  hand 
of  the  operator  and  drawn  strongly  down  toward  the  vulva. 

The  uterus  has  been  freed  from  its  surroundings  anteriorly  and  posteriorly  as 
described    in  Figures  132  and  133. 

A.  While  the  uterus  is  drawn  strongly  downward  and  to  one  side  with  vulsellum 
forceps  in  the  hand  of  an  assistant,  the  oj)erator  introduces  the  left  index  finger 
through  the  posterior  vaginal  opening  in  the  cul-de-sac  of  Douglas  and  brings  the 
finger-tip  out  into  the  vagina  through  the  anterior  opening,  so  as  to  hook  it  over  the 
left  broad  ligament ;  the  ligament  thus  held  on  the  finger  is  ti-ansfixed  at  two  points 
by  a  threaded  needle  passed  blunt  end  first,  so  that  the  ligature  shall  include  the  entire 
ligament  except  the  upper  and  lower  borders.  A  needle  passed  in  this  manner  is  a 
convenient  substitute  for  the  needle  with  the  eye  in  the  point  shown  in  D. 

B.  The  needle  has  been  drawn  through  the  broad  ligament,  leaving  the  ligature  in 
place  ready  ,to  be  tied. 

C.  The  ligature  has  been  tightly  tied  and  is  being  secured  against  possible  slipping 
by  an  additional  stitch  on  the  proximal  side  of  it ;  the  entire  ligature  when  tied  is 
shown  in  Figure  135.  Observe  that  the  ligature  does  not  compress  the  entire  liga- 
ment, but  leaves  out  a  margin  on  the  upper  and  lower  border,  so  that  collateral  circu- 
lation may  continue  to  supply  and  keep  alive  the  distal  portion  of  the  stump ;  this 
prevents  gangrene  and  sloughing  of  the  stump,  and  is  therefore  a  very  essential  feature 
of  the  operation. 

D  shows  the  fomi  of  needle  in  general  use  for  ligature  of   the  broad  ligament. 
The  device  of  an  ordinary  needle  passed  by  a  needle-forceps,  blunt  end  fii-st,  is  more 
simple,  and  because  any  size,  curve,  or  form  of  needle  may  be  used  at  a  constantly 
varying  angle  to  the  forceps,  is  more  practical. 
312 


Figure  134 


313 


Figure  135 


314 


EXPLANATIOX   OF   FiGURE    135. 

Vaginal  Hysterectomy.     The  patient  is  in  the  dorsal  position. 
The  vagina  and  cervix  uteri  are  exposed  by  reti-actors  in  the  hands  of  assistants. 
The  OS  uteri  externum  has  been  closed  by  a  continuous  suture  to  protect  the  opera- 
tion wound  and  the  peritoneum  from  the  uterine  secretions. 

A.  The  cervix  uteri  is  drawn  strongly  downward  and  to  one  side  by  vulsellum 
forceps  in  the  hand  of  an  assistant ;  the  left  broad  ligament  having  been  ligatured  en 
masse  as  shown  in  Figure  134,  is  exposed  by  the  operatoi-'s  left  index-finger  and  is  cut 
from  the  uterus  about  one-half  inch  from  the  ligature  with  scissors  in  the  operator's 
right  hand. 

B.  The  uterus  having  been  freed  from  its  attachment  anteriorly,  posteriorly,  and 
on  the  left,  is  drawn  outside,  and  the  corpus  is  seized  with  another  pair-  of  forceps ; 
these  forceps,  together  with  those  on  the  cei-vix,  are  placed  in  the  hand  of  an 
assistant,  who  makes  ti-action  on  them,  thus  pulling  the  doubled  uterus  strongly  down- 
ward and  to  one  side,  while  the  operator  ligatures  en  masse  and  severs  the  right  broad 
ligament  in  a  manner  precisely  similar  to  that  already  described  for  tying  and  cutting 
the  left ;  the  uterus  having  thus  been  removed,  the  vaginal  wound  is  closed  by  inter- 
rupted or  running  catgut  sutures,  as  shown  in  Figure  137.  These  sutures  may  secure 
both  the  peritoneal  and  vaginal  margins  of  the  wound  or  only  the  pei'itoneal  margins  ; 
in  either  case  they  should  so  include  the  ligatured  stumps  of  the  broad  ligaments  as  to 
fix  them  in  the  wound  where  they  may  give  normal  support  to  the  rectum,  vagina, 
and  bladder.  If  drainage  is  required,  the  wound  should  be  left  partially  or  wholly 
open  for  that  purpose.  The  central  third  of  the  wound,  if  not  sutured,  will  usually 
suffice  for  drainage.     The  gauze  drain  is  commonly  preferred. 

315 


Explanation  of  Figure  lotj. 

In  the  majority  of  cases  it  is  impracticable  to  include  the  entire  broad  ligament  in  a 
single  ligature,  and  it  is  necessary  therefore  to  tie  it  in  parts ;  this  is  called  progressive 
ligature  of  the  broad  ligament. 

A  shows  the  broad  ligament  being  progi-essively  tied  from  the  lower  to  the  upper 
margin  ;  the  fii-st  ligatui-e  is  being  introduced  on  the  lower  margin.  As  each  ligatui-e 
is  introduced,  the  ligatured  portion  is  cut  until  the  entire  ligament  is  severed  from  the 
uterus. 

£.  In  some  cases  the  ligament  is  too  inaccessible  for  progressive  ligature  from  the 
lower  to  the  upper  margin ;  then  the  coi-pus  uteri  may  be  delivered  through  the 
anterior  vaginal  wound  and  drawn  by  strong  forceps  to  the  vulva,  so  as  to  twist  the 
ligament  on  itself  and-  thereby  reduce  the  size  of  it  and  render  it  accessible  for  pro- 
gressive ligature  from  the  upper  to  the  lower  border ;  the  beginning  of  such  a  ligature 
is  here  shown. 

C  In  some  cases  the  ligaments  are  inaccessible  for  ligature  in  the  mannere 
described  under  A  and  B.  The  uterus  may  then  be  seized  by  two  strong  forceps, 
one  on  either  side  of  the  cervix,  drawn  strongly  toward  the  vulva,  bisected  with 
scissors  in  the  median  line  of  the  longitudinal  axis,  and  each  half  drawn  outside ;  the 
ligaments  may  then  be  ligatured  and  the  uterus  thus  removed  in  two  parts.  Eesec- 
tion  of  the  uterus  should  be  avoided  when  possible,  for  it  exposes  the  wound  to  infec- 
tion from  the  endometrium. 
316 


i 


Figure  136 


317 


Figure  137 


318 


Explanation  of  Figure  137. 

In  most  cases  the  ligatured  stumps  of  the  broad  ligaments  can  be  drawn  down  into 
the  vagina.  In  such  cases  the  usual  method  has  been  to  fasten  them  by  sutures  at 
each  end  of  the  closed  vaginal  wound,  in  such  a  way  that  the  ligatured  stumps  shall  be 
in  the  vagina  below  the  level  of  the  vaginal  wound.  The  ligatures  are  applied  by 
many  operators  en  masse  around  the  entire  ligaments  in  such  a  way  that  the  ligatured 
portion  will  slough.  It  is  sometimes  possible  to  apply  ligatures  so  that  no  sloughing 
can  occur ;  that  is,  to  let  the  ligatures  include  only  that  portion  of  the  ligament 
through  which  the  arteries  pass.  This  plate  shows  a  very  practical  method  of  treating 
the  ligatured  ends  of  the  broad  ligaments  in  such  a  manner  as  to  avoid  sloughing  of 
the  ligatured  stumps  and  to  fix  them  in  the  vaginal  wound.  The  method  hei'e  illus- 
trated is  applicable  only  to  those  cases  in  which  the  ligaments  are  sufficiently  long  to 
permit  either  end-to-end  approximation  or  the  folding  of  one  upon  the  other  and  the 
fixation  of  them  in  the  vaginal  wound  between  the  vaginal  and  peritoneal  sides  of  it. 

A.  The  ligaments  having  been  ligatured  en  masse  in  such  a  manner  as  to  avoid 
sloughing  of  the  ligatured  stumps,  are  drawn  down  into  the  vagina  by  means  of 
pressure-forceps.  The  anterior  peritoneal  margin  of  the  vaginal  wound  is  being 
united  to  the  posterior  margin  by  a  continuous  catgut  suture.  At  both  ends  of  the 
line  of  union  this  continuous  suture  secures  the  broad  ligaments,  so  that  they  cannot 
slip  back  into  the  pelvic  cavity.  Only  one  ligature  is  here  shown  on  each  broad  liga- 
ment.    In  the  majority  of  cases  more  than  one  ligature  may  be  required. 

B.  The  anterior  and  posterior  peritoneal  margins  having  been  united,  as  shown  in 
A,  the  broad  ligaments  are  brought  together  by  end-to-end  approximation  and  united 
by  a  continuous  catgut  suture.  The  united  ends  of  the  broad  ligaments  are  now  in 
contact  with,  and  in  front  of,  the  united  peritoneal  margins,  shown  in  A. 

O.  The  anterior  and  posterior  margins  of  the  peritoneal  wound  have  been  united, 
and  the  broad  ligaments  have  been  approximated  end-to-end  by  continuous  sutures,  as 
shown  in  A  and  B.  The  anterior  and  posterior  margins  of  the  vaginal  mucosa  are 
being  united  by  a  continuous  catgut  suture,  making  a  line  of  union  from  side  to  side. 
This  suture  completes  the  opei-ation. 

D.  In  some  cases  the  broad  ligaments  are  so  long  that  instead  of  uniting  them 
end-to-end  they  may  be  folded  one  upon  the  other,  and  so  fastened  together.  The 
anterior  and  posterior  peritoneal  margins  have  been  united  in  precisely  the  same 
manner,  as  shown  in  ^. 

E.  The  anterior  and  posterior  peritoneal  margins  of  the  vaginal  wound  have  been 
united  by  a  transverse  line  of  union,  as  shown  in  A  and  D.  The  ends  of  the  broad 
ligaments  have  been  folded  upon  themselves,  and  are  being  united  by  a  continuous 
catgut  suture  along  the  lower  borders  of  them.  A  similar  suture  is  to  be  introduced 
along  the  upper  borders.  The  ligaments  having  thus  been  united,  are  to  he  covered 
by  union  of  the  upper  and  lower  margins  of  the  vaginal  mucosa,  as  shown  in  C. 

The  method  of  fixing  the  ends  of  the  broad  ligaments  between  the  peritoneal  and 
vaginal  sides  of  the  wound  will  be  found,  when  practicable,  to  have  great  value,  for 
the  ligaments  so  fixed  can  then  perform  the  important  function  of  holding  the  pelvic 
viscera  high  up  in  the  pelvis  and  of  preventing  prolapse  of  the  pelvic  floor  ( rectum, 
vagina,  and  bladder),  a  not  uncommon  and  most  unfortunate  result  of  vaginal  hys- 
terectomy when  performed  by  the  older  methods. 

The  method  of  overlapping  the  ligaments  will  always  be  possible  in  the  operation 
of  vaginal  hysterectomy  when  performed  for  complete  procidentia  uteri,  and  is  strongly 
urged  in  tha"t  class  of  cases ;  when  the  ligaments  are  not  sufficiently  long  for  end-to-end 
approximation,  they  may  be  fixed  in  the  vaginal  wound,  as  described  in  the  text,  or  if 
not  sufficiently  long  for  this,  may  have  to  be  returned  to  the  pelvic  cavity. 

Observe  in  E  and  D  the  isolated  ligature  of  the  arteries.  This  forin  of  ligature 
will  usually  be  quite  practicable,  except  for  very  short  and  very  large  ligaments,  and 
when  practicable  should  always  be  employed,  because  it  insures  normal  circulation  in 
the  stumps  and  is  an  absolute  safeguard  against  sloughing.  It  should,  however,  be 
remembered  that  in  hysterectomy  for  cancer  there  is  a  decided  advantage  in  removing 
as  much  of  the  ligament  as  possible ;  hence,  the  ligature  en  masse  in  such  cases  may 
be  preferable. 

319 


Figure  138 


320 


Explanation  of  Figure  138. 

A.  Same  as  Figure  135,  B,  except  that  forceps  are  used  for  hsemostasis  instead  of 
ligatures.  One  pair  of  forceps  has  been  applied  to  the  right  broad  ligament  and  the 
ligament  has  been  severed  partially  by  means  of  scissoi"s.  The  second  pair  of  forceps 
is  being  applied  previous  to  cutting  the  ligament  entirely  away  from  the  uterus.  The 
removal  of  the  uterus  is  accomplished  when  the  same  procedure  has  been  repeated  on 
the  other  broad  ligament.  Figure  f  shows  full  size  of  the  jaw  of  the  pressure-forceps 
here  used. 

B.  Hsemostasis  secured  by  one  pair  of  pressure-forceps  on  the  right  ligament  and 
two  pairs  on  the  left  ligament.  The  vaginal  wound  is  being  closed  by  continuous  cat- 
gut sutures.  The  peritoneal  layer  has  been  closed.  The  vaginal  layer  is  being  closed. 
Observe  that  the  suture  includes  not  only  the  margins  of  the  wound,  but  also  the 
ligament. 

C.  The  peritoneal  margins  of  the  wound  are  here  being  held  together  by  means  of 
small  hsemostatic  forceps,  which  are  used  in  place  of  sutures.  The  method  of  closure 
with  forceps  is  indicated  when,  for  any  i-eason,  such,  for  example,  as  di-ainage,  the 
wound  should  not  be  closed  entirely,  or  when  the  low  condition  of  the  patient 
does  not  permit  the  operation  to  be  prolonged  by  suturing.  The  forceps  here  hold 
the  peritoneal  margins  together  and  serve  to  keep  intestines  and  other  abdominal 
viscera  from  protruding  into  the  vagina.  When  forceps  are  used  in  this  way  the  vag- 
inal margins  of  the  wound  are  left  open,  and  the  vagina  is  packed  with  gauze.  All 
forceps  and  gauze  should  be  removed  within  three  days,  and  after  the  removal  of  the 
gauze  the  vagina  should  be  gently  douched  twice  d?ily  with  a  0.25  per  cent,  solution 
of  lysol.     The  vulva  should  be  dressed  antiseptically. 

321 


322  INFECTIONS,  INFLAMMATIONS,   AND  ALLIED  DISORDERS. 

ill  the  vagina  is  occupied  by  forceps  as  to  impede  the  operator,  a  single 
forceps  may  be  applied  back  of  two  or  more,  and  the  latter  then 
removed.  Some  operators  leave  the  vaginal  wound  open  for  drainage 
with  or  without  gauze  packing.  If  no  packing  is  used,  the  peritoneal 
margins  of  the  wound  usually  fall  together  and  promptly  unite. 
Numerous  cases,  however,  of  annoying  intestinal  adhesions,  protrusion 
of  the  bowel,  fecal  fistula,  intestinal  obstruction,  and  peritonitis  prove 
the  danger  of  the  open  treatment.  The  wound  may  be  closed  by  the 
continuous  or  interrupted  catgut  suture,  or,  as  shown  in  Figure  138,  E, 
by  small  pressure-forceps.  If  drainage  is  required,  a  small  rope  of 
twisted  gauze  or  a  rubber  tube,  or  both,  may  be  inserted  between  the 
sutures  precisely  as  would  be  done  in  closing  any  other  wound.  The 
vagina  then  is  packed  lightly  with  gauze,  and  absorbent  dressing  is 
secured  to  the  vulva  by  a  T-bandage,  and  changed  sufficiently  often  to 
keep  it  dry. 

Whenever  practicable  the  broad  ligament  stumps  should  be  drawn 
down  into  the  vagina  and  fixed  there  by  catgut  sutures,  so  that  every- 
thing included  in  the  bite  of  the  forceps  may  be  in  the  vagina.  The 
advantage  of  this  is  twofold  :  1 .  All  traumatisms,  except  the  simple 
peritoneal  wound,  are  excluded  from  the  peritoneum.  2.  The  liga- 
ments, when  united  to  the  upper  end  of  the  vagina,  support  the  pelvic 
floor,  and  with  it  the  rectum,  bladder,  and  vagina,  so  that  enterocele 
vaginalis  is  prevented.     See  Figure  138. 

Accidents  of  Vaginal  Hysterectomy. — Rectovaginal  and  vesico- 
vaginal fistulse  are  among  the  accidents  of  vaginal  hysterectomy. 
Should  either  of  these  accidents  occur,  it  is  only  necessary  to  use 
additional  interrupted  sutures  at  the  point  of  the  fistula  in  uniting  the 
peritoneal  edges  to  the  vaginal  edges  of  the  wound  anterior  and  pos- 
terior to  the  uterus  by  the  whip-stitch  already  described.  These 
sutures  should  not  be  buried,  but  should  include  the  peritoneal  and 
vaginal  margins  so  that  peritoneum  will  cover  the  fistula.  The  strong 
tendency  of  peritoneal  surfaces  to  adhere  to  any  exposed  surface 
renders  closure  of  the  fistula  by  this  means  almost  certain. 

After-treatment  of  Vaginal  Hysterectomy. — The  general  pro- 
cedure in  after-treatment  differs  in  nothing  from  that  of  ordinary 
abdominal  section.  The  forceps  and  vaginal  gauze  and  the  drain, 
if  there  be  one,  should  be  removed  at  the  end  of  forty-eight  hours, 
and  a  0.5  per  cent,  lysol  douche  given.  If  the  wound  has  been  left 
open  and  packed  with  gauze,  great  care  should  be  used  lest  in  the 
removal  of  the  ganze  a  loop  of  intestine  be  drawn  into  the  vagina. 
The  douche  may  be  repeated  daily,  or,  if  the  discharges  are  fetid, 
oftener.  Let  the  douche  be  a  weak  current,  lest  it  force  its  way 
through  the  fresh  adhesions  into  the  general  peritoneum. 

Relative  Merits  of  the  Ligature  and  Forceps  Operation. — Tlie 
advantage  of  pressure-forceps  over  the  ligature  are  :  1 .  The  greater 
facility  of  application  very  materially  shortens  the  operation  ;  therefore 
in  a  difficult  case,  with  inaccessible  broad  ligaments,  they  are  safer.  2. 
The  forceps  may  be  made  to  grasp  a  considerable  portion  of  the 
broad  ligament ;  the    ligament    may    be    drawn    down    and    grasped 


SURGICAL   TREATMENT  OF  SALPINGITIS.  323 

further  back  by  other  forceps ;  more  of  the  ligament  may  in  this 
way  be  included  than  would  be  possible  with  the  ligature.  What- 
ever the  forceps  grasp  will  slough ;  by  this  means  a  very  large  por- 
tion of  the  ligament  may  be  destroyed.  This  would  be  a  more  impor- 
tant consideration  if  the  operation  were  being  performed  for  malignant 
disease.  Some  part  of  the  disease  which  the  ligature  might  have 
missed  therefore  may  be  removed  with  the  slough.  3.  The  forceps 
facilitate  drainage.  The  secretions  find  their  way  out  along  the  solid 
instrument  by  continuity  of  surface.  4.  If  the  forceps  are  constructed 
and  applied  properly,  the  security  against  secondary  hemorrhage  is 
almost  absolute. 

The  disadvantages  of  the  forceps  as  compared  with  the  ligature  are  : 
1.  They  cause  great  suifering  to  the  patient.  2.  Their  removal  is 
painful.  3.  Convalescence  is  apt  to  be  more  protracted  and  com- 
plicated. 

Both  the  ligature  and  the  forcipressure  operations  are  efficient  and 
satisfactory ;  therefore,  whichever  is  most  convenient  or  will  most 
facilitate  the  operation  should  be  used.  The  forceps  will  often  be 
preferable  in  grave  cases,  especially  when  the  ligaments  are  very  thick 
and  inaccessible.     Both  methods  may  be  useful  in  the  same  case. 

Combined  Operation  of  Abdominal  and  Vaginal  Section. — 
Wlien  the  vulva  and  vagina  are  small  and  the  uterus  is  large,  high  in 
the  pelvis,  or  fixed,  removal  of  it  through  the  vagina  will  be  very 
difficult.  Under  these  conditions,  after  making  the  vaginal  incisions 
and  separating  the  cervix  from  its  surroundings,  as  already  described, 
the  operation  may  be  finished  better  through  an  abdominal  opening. 
Tlie  technique  is  the  same  as  that  described  for  hysteromyomectomy. 

The  difficulties  of  vaginal  hysterectomy  are  much  increased  when 
the  uterus  and  its  appendages  are  fixed  by  adhesions.  The  uterus 
being  drawn  down  and  steadied  by  the  vulsellum  forceps  in  the  right 
hand,  the  adhesions  are  broken  up  by  the  finger  precisely  as  in  the 
operation  already  described  for  removal  of  the  appendages.  The 
adherent  appendages  having  been  freed,  the  operation  proceeds  as  if 
there  had  been  no  adhesions. 

Drainage. — The  class  of  cases  discussed  above  ofPers  a  large  field 
for  drainage.  Gauze  is  preferable  to  tubular  drainage.  The  tech- 
nique of  vaginal  drainage  is  described  in  Chapter  VII.  The  clamps, 
if  left  on  the  broad  ligaments  for  hsemostasjs,  also  in  a  measure  serve 
the  purpose  of  drainage.  They  should  be  removed,  however,  at  the 
end  of  forty-eight  to  seventy-two  hours. 

Hysterectomy  without  Removal  of  the  Appendages. — When 
the  appendages  are  firmly  matted  and  bound  together,  and  almost 
inseparable  from  the  surrounding  structures,  and  their  removal  is  prac- 
tically forbidden  by  the  desperate  risk  of  the  operation,  tlie  uterus  may 
be  rernoved  and  the  pus-sacs  freely  opened  and  left  to  drain  into  the 
vagina.  Even  if  some  pus-pockets  are  overlooked,  they  probal)ly 
will  break  sooner  or  later  into  the  wound.  Such  pus-sacs,  whether 
tubal,  ovarian,  or  parametric,  when  drained  in  this  way,  as  a  rule, 
undergo  atrophy  and  become  obliterated.  Although  this  partial 
operation  is  only  permissible  for  the  reasons  given  above,  yet  it  has 


324  INFECTIONS,   INFLAMMATIONS,   AND  ALLIED  DISORDERS. 

been  followed  by  entirely  satisfactory  results.     An  explanation  in  the 
following  paragraph  is  submitted. 

The  removal  of  the  appendages  and  consequent  cutting  off  of  the 
vascular  and  nervous  connections  of  the  uterus  are  followed  usually  by 
atrophy,  cessation  of  function,  and  subsidence  of  disease  in  that 
organ  ;  conversely,  similar  results  in  the  Fallopian  tubes  and  ovaries 
naturally  should  follow  the  cutting  off  of  their  vascular  and  nerve 
connections  by  the  removal  of  the  uterus.  In  one  recorded  case  of 
hysterectomy  the  remaining  tubes,  however,  became  healthy  and  did 
not  atrophy.  On  the  contrary  they  were,  during  several  years  after 
the  operation,  the  medium  of  apparent  menstruation,  the  menstrual 
fluid  passing  from  them  into  the  vagina.^  This  case  speaks  against 
the  idea  that  the  tubes  do  not  participate  in  menstruation.  In  another 
case  ^  pregnancy  occurred  in  the  isthmic  portion  of  the  tube ;  there 
was  consequent  hemorrhage  into  the  vagina ;  the  tubal  opening  was 
dilated  and  the  product  of  conception  curetted  away. 


Aspiration  of  Hydrosalpinx  through  the  Vagina. 

The  contents  of  sactosalpinx  serosa — hydrosalpinx — may  be  re- 
moved by  aspiration,  and  permanent  cure  may  result.  As  explained 
in  Chapter  XXI.,  occlusion  of  the  ends  of  the  distended  tube  may 
have  occurred  mechanically  from  swelling  of  the  mucosa  or  organ- 
ically from  adhesive  inflammation.  Spontaneous  reopening  of  the 
tube  and  restoration  of  its  functions  are  probable  under  the  former, 
improbable  under  the  latter  conditions. 

Technique  of  Aspiration. — The  diagnosis  of  sactosalpinx  serosa — 
hydrosalpinx — having  been  made,  the  aspiration  of  it  will  include  the 
following  steps  : 

1.  Make  the  vulva  and  vagina,  so  far  as  possible,  aseptic. 

2.  Locate  the  sac  accurately  by  conjoined  examination. 

3.  Keeping  the  right  hand  behind  the  pubes  over  the  sac,  and 
using  the  left  index  and  middle  fingers  in  the  vagina  as  a  guide  to  the 
point  where  the  sac  bulges  most  toward  the  vaginal  fornix,  push  the 
aspirator  needle  into  the  sac  with  the  left  hand. 

4.  If  fluid  does  not  follow,  withdraw  the  needle  slightly  and  push 
it  in  again. 

5.  Having  withdrawn  the  fluid,  the  action  of  the  aspirator  may  be 
reversed  and  the  sac  refilled  and  again  emptied  two  or  three  times 
with  a  0.1  per  cent,  solution  of  formalin. 

6.  The  aspiration  and  washing  out  of  the  sac  having  been  com- 
pleted, place  a  pledget  of  wool  or  gauze  saturated  with  a  10  per  cent, 
solution  of  ichthyol  and  glycerin  against  the  cervix  uteri. 

The  fluid  having  been  removed,  it  should  be  subjected  to  a  bacte- 
riological examination,  and  if  found  sterile  a  permanent  cure  may  be 
anticipated. 

1  Weller  Van  Hook.    Unpublished  case. 

2  Wendener.    Centralblatt  fiir  Gynakologie,  18%,  No.  4.  p.  111. 


SURGICAL  TREATMENT  OF  SALPINGITIS.  325 

Vaginal  Incision  and  Drainage. 

Incision  and  drainage  is  a  recognized  procedure  : 

1.  In  the  treatment  of  chronic  sactosalpinx. 

2.  In  the  treatment  of  acute  pelvic  suppuration. 

3.  As  a  temporizing  measure  in  grave  cases. 

1.  Incision  and  Drainage  for  Chronic  Sactosalpinx. — Incision 
and  drainage  of  sactosalpinx  is  not  expected,  even  when  successful,  to 
restore  the  function  of  the  tube,  but  to  produce  instead  complete 
obliteration  of  the  lumen,  thereby  converting  the  tube  into  a  cord. 
The  same  process  sometimes  occurs  spontaneously  as  a  result  of  recur- 
ring appendicitis  or  recurring  salpingitis.  The  disease  is  then  known 
as  appendicitis  obliterans  or  salpingitis  obliterans,  a  result  which 
incision  and  drainage  may  bring  about  or  hasten. 

There  will  always  be  great  difficulty  in  drawing  the  line  between 
those  cases  which  may  be  relieved  by  the  operation  and  those  which 
demand  extirpation  of  the  diseased  organs.  The  former  treatment 
will  be  applicable  to  the  more  recent  and  acute  cases,  the  latter  to 
the  older  chronic  suppurative  cases  in  which  permanent  changes  have 
taken  place.  Notwithstanding  the  numerous  successful  cases  reported 
by  Vulliet,  Landau,  Goulliad,  Abbott,  and  others,  the  operation  is  not 
very  strongly  indicated  in  chronic  pyosalpinx.  Success  requires  the 
removal  of  old  and  prevention  of  new  infection  ;  and  the  fulfilment 
of  this  requirement  in  the  many  possible  cavities  and  recesses  of  a 
pus-tube,  and  in  the  neighboring  pus-pockets  whose  walls  are 
infected  deeply,  is  often  beyond  the  power  of  simple  drainage  and 
disinfection. 

This  operation,  which  had  been  nearly  obsolete  for  twenty  years, 
was  revived  after  the  development  of  aseptic  abdominal  surgery. 
Before  this  time  it  had  shown  relatively  few  immediate  cures  and  a 
discouraging  number  of  failures  to  cut  short  tubal  and  ovarian  sup- 
puration. On  the  other  hand,  the  more  radical  operation  of  extir- 
pating the  diseased  organs  has  saved  innumerable  women  from  life- 
long invalidism  or  death.  The  re-establishment  of  incision  and 
drainage  as  a  recognized  and  useful  procedure  has  been  made  possible 
by  the  introduction  of  sharp  uterine  curettage  and  asepsis.  The 
operration  should -include  the  thorough  removal  of  any  infection  in 
the  uterus  by  aseptic  sharp  curettage.  Failure  in  this  may  lead  to 
disastrous  results. 

When  the  distended  Fallopian  tube  can  be  isolated  by  palpation, 
incision  and  drainage  is  performed  as  follows  :  First  the  vagina  and 
vulva  are  disinfected  thoroughly,  the  patient  being  in  the  lithotomy 
position ;  the  sactosalpinx  by  steady  pressure  of  the  assistant's  hand 
is  now  fixed  downward  toward  the  vagina,  and  a  trocar  properly 
curved  or  straight,  guided  by  the  left  index-finger,  is  introduced  into 
the  sac.  On  this  trocar  as  a  guide,  sharp-pointed  scissors  are  used  to 
enlarge  the  opening  by  working  their  point  through  the  wall  with 
alternate  spreading  and  closing  of  the  blades  until  the  finger  can  be 
introduced  into  this  abscess  cavity.  The  sac  is  washed  out  with  a 
1  :  1000  solution  of  formalin. 


326    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

The  drainage  may  be  capillary  or  tubular  as  described  in  Chapter 
VII.  On  account  of  a  strong  tendency  for  the  vaginal  opening  to 
close,  it  may  be  necessary  every  few  days  to  insert  the  blades  of  a 
long  haemostatic  forceps  and  separate  them  by  spreading  the  handles. 
After  the  first  week  or  two  the  drains  may  be  removed.  The  vagina 
should  be  kept  clean  by  means  of  antiseptic  douches. 

The  prognosis  after  incision  and  drainage  is  better  for  hydrosal- 
pinx than  for  pyosalpinx  and  best  for  cellulitic  abscess. 

Tubet^cular  Suppuration  offers  great  resistance  to  all  conservative 
measures,  and  therefore  is  admitted  generally  to  be  an  indication  for 
the  removal  of  the  uterus  and  its  appendages.  The  great  frequency 
of  chronic  tubercular  infection  materially  cuts  down  the  number  of 
cases  suitable  for  drainage.  It  is,  moreover,  usually  difficult  to  rec- 
ognize and  exclude  the  tubercular  cases  until  the  diseased  tissue  has 
been  removed  and  examined.    The  pus  is  often  sterile.    The  suggestion 

FTGtTRE  139 


Tubercular  perimetritis  and  salpingitis  ;  sactosalpinx.    Uterus  and  appendages  removed 

complete. 

to  defer  the  radical  operation  until  conservative  measures  have  been 
tried  and  failed,  is  weakened  by  the  fact  that  after  incision  and  drain- 
age removal  of  the  diseased  organs  is  always  more  difficult,  tedious, 
and  dangerous. 

2.  Incision  and  Drainage  for  Acute  Pelvic  Suppuration.^ — 
The  pelvic  organs  and  products  of  inflammation  may  be  so  matted  and 
fused  together  in  a  conglomerate  mass  that  the  individual  organs  are 
unrecognizable  and  the  patient's  general  state  from  septic  poisoning 
may  be  so  grave  as  to  prohibit  a  radical  operation.  In  such  condi- 
tions, whether  the  suppuration  ])e  tubal,  ovarian,  or  parametric,  or  all 
combined,  vaginal  incision  and  drainage  offer  the  following  advan- 
tages:  1.  Relative  freedom  from  mortality.  2.  Probable  preservation 
and  possible  restoration  to  function  of  the  diseased  organs. 

The  operation  begins   with  preliminary  sharp  curettage,  Chapter 

1  Fernand  Henrotin,  "  The  Conservative  Surgical  Treatment  of  Para-  and  Peri-uterine  Septic 
Disease."    Transactions  of  the  American  Gynecological  Society,  1885.    Adaptation. 


SURGICAL   TREATMENT  OF  SALPINGITIS. 


327 


XXVII.,  and  is  continued  as  follows  :  The  incision  is  made  behind 
the  uterus,  as  already  described  in  this  chapter,  for  posterior  vaginal 
section,  and  the  finger  is  introduced  into  Douglas's  pouch,  which  gen- 
erally is  shut  oif  from  the  general  peritoneal  cavity  by  the  adhesions. 
If  the  post-uterine  circular  incision  gives  too  little  space  for  thorough 
intrapelvic  exploration  and  manipulation,  an  additional  perpendicular 
incision  may  be  made  from  the  centre  of  the  first  incision.  Figure  131, 
in  the  median  line  of  the  posterior  vaginal  wall  from  the  cervix  uteri 
toward  the  rectum.  During  the  making  of  the  second  incision  the 
index-finger  of  the  left  hand  should  be  in  the  rectum  as  a  guide  to 
prevent  wounding  the  bowel.  This  finger,  after  thorough  disinfec- 
tion and  change  of  rubber  glove,  now  being  returned  to  the  pouch 

Figure  140. 


Incision  through  the  vagina  of  a  pelvic  abscess  with  sharp-pointed  scissors. 

of  Douglas,  and  the  right  hand  being  over  the  abdomen,  the  exam- 
ination proceeds  as  in  the  ordinary  bimanual  palpation.  The  exam- 
ining finger  penetrates  backward  and  to  either  side  until  the  bimanual 
sensation  indicates  that  the  free  peritoneum  almost  is  reached.  In 
shifting  the  finger  to  the  right  or  to  the  left,  and  with  it  the  super- 
imposed hand,  the  septic  mass  usually  will  be  found  and  penetrated 
Avithout  difficulty. 

In  most  cases  the  infiltrated  material  will  be  evident  to  the  touch 
of  the  examining  finger  and  an  abscess-cavity  usually  will  be  found. 
The  accidental  opening  of  the  peritoneal  cavity  during  these  manip- 
ulations does  not  materially  increase  the  danger ;  but  if  this  accident 


328    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

occurs,  it  is  well  to  retain  the  finger  in  the  opening  leading  to  the 
abscess  until  any  escaping  pus  may  be  washed  out  of  tlie  vagina  and 
the  peritoneal  cavity  protected  by  gauze  packing  against  the  inflow- 
ing of  pus.  The  finger  should  then  be  withdrawn  and  the  pus- 
cavity  evacuated.  Gentle  pressure  upon  the  abdominal  wall  will  help 
to  empty  the  abscess.  The  protective  packing  in  the  peritoneal  cavity 
is  replaced  now  by  fresh  gauze  and  the  finger  reintroduced  into  the 
pus-cavity.  This  is  for  the  purpose  of  finding  and  emptying  any 
adjacent  abscesses.  Both  sides  of  the  pelvis  having  been  thor- 
oughly explored  in  this  way  and  all  hard  inflammatory  masses, 
whether  pus-containing  or  not,  having  been  penetrated  by  the 
finger,  the  cavities  thus  opened  should  be  packed  with  a  single 
strip  of  sterilized  gauze  about  three  inches  wide,  the  outer  end  of 
which  should  be  retained  carefully  in  the  vagina  to  facilitate  removal. 
It  is  well  also  to  pass  into  the  vaginal  wound  by  the  side  of  the 
gauze  a  large  rubber  tube  in  order  to  insure  efficient  drainage.  The 
operation  is  completed  by  the  application  of  a  light  vaginal  gauze 
tampon  and  by  a  pad  over  the  vulva  which  should  be  held  in  place 
by  a  T-bandage.  No  instrument  excepting  the  finger  should  be  used 
after  the  preliminary  incision  through  the  vaginal  wall  has  been  made. 

The  inflammatory  deposit  in  many  cases  will  be  found  in  the  median 
line  posterior  to  the  uterus ;  in  other  cases  it  will  be  found  on  one 
or  both  sides.  In  such  cases  the  finger  cannot  be  worked  back  in  the 
median  line  very  far  without  penetrating  the  abdominal  cavity,  but 
turning  it  to  either  side  it  may  usually  be  made  to  separate  the  layers 
of  the  broad  ligament,  and  without  invading  the  peritoneum  at  all 
mav  be  pushed  into  the  lateral  masses. 

3.  Incision  and  Drainage  as  a  Temporizing-  Measure. — In  acute 
or  chronic  pelvic  suppuration  when  the  condition  of  the  patient  is  so 
grave  as  to  prohibit  a  more  radical  operation  not  excluding  even 
tubercular  cases  which  generally  require  removal  of  the  uterus  and  its 
appendages  (pan-hysterectomy),  incision  and  drainage  is  indicated  ; 
and,  though  performed  as  a  temporizing  measure,  there  is  usuallv  such 
prompt  and  pronounced  improvement  as  to  permit  a  radical  operation 
later. 

The  mortaluy  of  opening  into  the  peritoneal  cavity  by  either  route  in 
acute  suppuration  before  the  pus  has  had  time  to  become  sterile  is 
excessive.  The  withdrawal  of  such  cases  from  laparotomy  statistics  and 
the  relegation  of  them  to  the  statistics  of  vaginal  incision  and  drainage 
would  reduce  enormously  the  mmiality  of  abdominal  surgery. 

Relative  Advantages  and  Disadvantages  of  the  Abdominal  and 
Vaginal  Routes  in  Pelvic  Surgery. 

Advantages  of  the  Abdominal  Route.— 1.  There  is  a  larger  field 
for  operation. 

2.  The  operator  may  see  what  he  is  doing,  instead  of  depending 
largely  on  the  sense  of  touch. 

3.  The  diagnosis  of  unsuspected  conditions  and  complications  is 
much  easier. 


SURGICAL   TREATMENT  OF  SALPINGITIS.  329 

4.  It  is  adapted  to  large  tumors  and  pus-sacs,  and  to  conditions 
high  in  the  pelvis. 

5.  The  appendages  may  be  removed  with  better  chance  of  avoiding 
rupture  of  a  pus-sac. 

6.  There  is  less  danger  of  wounding  intestine,  bladder,  or  ureter, 
and  greater  facility  in  the  control  of  hemorrhage. 

7.  Appendicitis  and  other  abdominal  lesions  so  often  complicating 
pelvic  disease  are  difficult  to  reach  by  the  vagina. 

8.  It  gives  more  light  and  more  space  for  conservative  work. 
Advantages  Claimed  for  the  Vaginal  Route. — 1.  It  gives  better 

drainage,  and  therefore  is  adapted  specially  to  complicating  vesical  or 
intestinal  fistula. 

2.  It  avoids  the  abdominal  scar  and  the  risk  of  ventral  hernia. 

3.  It  is  suitable  for  cases  of  small  tumors  without  high  adhesions. 

4.  When  properly  performed,  it  involves  less  danger  from  shock, 
and  therefore  is  suited  to  cases  of  extreme  pelvic  infiltration  and 
adhesions  for  which  the  abdominal  route  is  extra-hazardous. 

5.  It  involves  less  handling  of  the  intestines,  and  therefore  less 
consequent  danger  of  shock  and  intestinal  adhesions. 

6.  Recovery  is  less  complicated  and  more  rapid. 
Unfortunately,  the  vaginal  route  is,  for  a  large  proportion  of  cases, 

impracticable.  The  long,  narrow  virgin  vagina  or  the  vagina  which 
has  become  contracted  from  senile  atrophy  may  render  the  field  of 
operation  almost  inaccessible.  A  very  large  uterus  with  exceptionally 
short,  thick,  broad  ligaments  and  greatly  enlarged  appendages,  with 
adhesions  extending  beyond  the  reach  of  the  finger,  may  also  be  diffi- 
cult or  impossible  to  manipulate  through  the  vagina.  Under  such 
conditions  the  abdominal  route  is  much  safer. 

In  some  cases  it  is  well  to  begin  the  operation  in  the  vagina  and 
continue  by  that  route  as  far  as  the  greatest  safety  will  permit,  and 
then,  if  necessary,  open  the  abdomen  and  complete  the  operation  by 
the  combined  vaginal  and  abdominal  method.  Conversely,  abdominal 
section  may  have  to  be  supplemented  by  vaginal  section.  The  com- 
bined operation  may  be  the  deliberate  purpose  from  the  beginning,  or 
the  necessity  for  it  may  become  apparent  only  in  the  course  of  the 
operation. 

In  some  cases  the  advantages  of  the  two  routes  are  balanced  so 
evenly  that  either  is  permissible ;  the  election  then  must  rest  with  the 
individual  bias  of  the  surgeon.  The  choice  of  procedures  has  in  a 
measure  been  forecast  in  the  description  of  special  operations  already 
set  forth. 

It  will  be  seen  from  the  above  that  each  method  has  its  special 
advantages  and  disadvantages.  Some  of  these  last  are  less  real  than 
they  seem ;  for  example,  an  objection  to  vaginal  hysterectomy  is  that 
it  affords  only  a  limited  field  of  operation  and  small  chance  for  visual 
control  of  the  work.  This  objection  does  not  necessarily  appeal  to 
the  skilled  operator.  The  danger  of  hemorrhage  is  avoidable  if  due 
precautions  are  used.  Injuries  of  the  bladder,  ureters,  and  intestine 
may  occur  with  either  method,  but  in  vaginal  hysterectomy  the  perfect 
drainage  makes  them  less  dangerous  if  they  do  occur. 


330    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

TIm!  operator  should  not  permit  his  prejudice  in  favor  of  either 
route  to  lead  him  to  pursue  it  to  the  extreme,  for  that  part  of  an 
operation  which  is  easy  by  the  vagina  is  often  most  difficult  by  the 
abdomen,  and  vice  versa. 

The  vaginal  route  was  for  a  time  much  in  vogue,  but  at  present, 
even  among  conservative  surgeons,  there  is  a  tendency  to  return  to 
the  abdominal  route. 


Conservative  Operation  on  the  Fallopian  Tube.^ 

Salpingo -stomatomie. — Resection  of  the  Fallopian  tubes,  called 
salpingo-stomatomie,  is  designed  in  selected  cases  to  save  and  restore 
the  appendages  to  their  normal  function,  instead  of  removing  them. 
August  Martin  reports   65  cases  with  two  deaths,  neither  of  which 

Figure  1-11. 


Resection  of  the  tube.  The  distended  ampulla  to  the  right  closed  by  adhesive  inflamma- 
tion. The  ampulla  of  the  tube  to  the  left  has  been  removed  and  the  mucosa  is  being  united 
to  the  serosa  by  a  continuous  suture ;  the  longitudinal  slit  has  been  closed  by  a  continuous 
suture. 

was  attributable  to  the  operation.  In  1885  he  began  to  open  the 
closed  abdominal  ends  of  tubes  and  to  study  microscopically  their 
contents  and  the  condition  of  their  walls.     His  method  is  as  follows  : 

1.  Bring  the  tube  so  far  as  possible  up  into  the  abdominal  wound. 

2.  Protect  the  adjacent  pelvic  organs  by  sponge  packing  around 
the  tube. 

3.  Open  the  end  of  the  ampulla  with  scissors.  The  point  of 
closure  may  be  recognized  by  a  scar  in  which  the  fimbria?  are  still 
visible. 

4.  Strip  the  tube  of  fluid  by  pressure  applied  from  the  uterine 
toward  the  abdominal  end. 

5.  If  the  contents  be  serous,  odorless,  and  all  fluid,  and  the 
mucosa  shows  only  slight  swelling  and  reddening,  and  the  folds  are 
flattened  only  by  pressure,  slit  the  tube  for  a  distance  of  about  one 
inch. 

1  A.  Martin.    Die  Krankheiten  der  Eileiter,  p.  213, 


SURGICAL  TREATMENT  OF  SALPINGITIS. 


331 


6.  If  the  condition  in  the  upper  part  of  the  tube  still  appears  to 
be  only  catarrhal,  close  the  longitudinal  wound  with  three  fine  catgut 
sutures.     Any  large  superfluous  tags  are  to  be  cut  off. 

7.  The  borders  of  the  tubal  mucosa  at  the  end  of  the  tube  and  the 
peritoneum  are  to  be  united  by  fine  catgut  sutures  so  that  the  opening 
shall  gape  and  the  mucosa  shall  stay  everted. 

Hemorrhage  is  slight  and  easily  controlled  by  fine  ligatures.  The 
everting  sutures  at  the  end  of  the  ampulla  hold  the  new  ostium  close 
to  the  ovary.  The  now  reopened  tube,  together  with  the  ovary,  is 
replaced  in  the  abdomen.  Any  ovarian  adhesions  are  to  be  broken 
up.     According   to   Martin,  this  operation  offers   no  greater  danger 

Figure  142. 


Resection  of  the  ovary.  Conservative  operations  on  ovaries.  Partial  removal  of  right 
ovary  by  resection.  Nearly  all  of  left  ovary  preserved.  Small  detached  multiple  cyst  below 
left  ovary  has  been  removed  from  it.  The  ovaries  show  whip-stitches  for  closure  of  resection 
wounds. 


than  any  other  coeliotomy  complicated  by  peritonitis.  Pregnancy  fol- 
lowed in  two  cases  in  which  this  operation  had  been  performed  on  one 
side  and  the  appendages  had  been  extirpated  on  the  other. 

The  general  conclusion  is  that  extirpation  for  atresia  of  tubes 
whose  contents  are  not  infectious  may  be  unjustifiable.  The  opera- 
tion, however,  can  result  in  restoration  of  function  only  when  the 
uterine  end  is  open,  or  when,  if  closed,  the  closure  is  due  to  swelling 
and  not  to  inflammatory  adhesion.  The  surgeon  should  not  roiturc  to 
establish  a  communication  between  an  occluded  Fallopian  tube  and  the 
abdominal  cavity  unless  a  smear-  taken  from  the  secretion  at  the  time  of 
the  operation  proves  the  contents  of  the  tube  to  be  sterile. 


332    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Conservative  Operation  on  the  Ovary. 

Resection  of  the  Ovary. — The  diseased  portion  of  an  ovary  may 
be  removed  by  resection,  and  the  remaining  healthy  part  saved.  The 
indications  for  resection  are  these  : 

1.  The  saving  of  a  portion  of  the  ovary  in  order  to  preserve  its 
reproductive  functions. 

2.  The  saving  of  a  portion  of  the  ovary  in  order  to  preserve 
menstruation  and  other  possibly  important  functions  not  definitely 
known,  such  as  secretion  and  elimination. 

Reproduction  repeatedly  has  followed  the  operation  when  the 
uterus,  the  tube,  and  only  a  very  small  fragment  of  the  ovary  were 
left.  The  duty  of  the  surgeon  to  leave  for  this  purpose,  when  prac- 
ticable, any  functionating  part  of  an  ovary,  is  therefore  clear.^  The 
preservation  of  menstruation  and  other  possible  functions  is  urged  by 
many  competent  observers.  As  a  rule,  women  are  better  off  mentally 
and  physically  if  menstruation  and  ovulation  are  maintained  up  to 
the  period  of  nature's  menopause.  The  possible  secretory  and  elimi- 
native  functions  of  the  ovary  justify  the  operator  in  leaving  it,  or  any 
healthy  portion  of  it,  even  though  the  diseased  tubes  and  uterus  have 
to  be  removed.^ 

The  Operation  of  Resection  simply  involves  the  excision  by  scalpel 
or  scissors  of  the  diseased  portion  and  closure  of  the  wound  by  means 
of  fine  interrupted  or  continuous  catgut  sutures. 

All  conservative  operations  for  opening  closed  tubes  and  resection 
of  ovaries  should  be  supplemented  by  the  release  of  the  appendages 
from  any  adhesion  which  may  be  present. 

Ovarian  Extract  or  Desiccated  Ovaries,  which  may  be  found  in 
drug-shops  prepared  for  internal  administration,  are  recommended 
highly,  and  are  said  to  give  relief  to  the  disagreeable  symptoms  of 
the  menopause,  whether  induced  by  oophorectomy  or  by  nature. 

1  Polk.  "  Operations  on  the  Uterine  Appendages,  with  a  View  to  Preserving  the  Functions 
of  Ovulation  and  Menstruation."    Transactions  or  the  American  Gynecological  Society,  1893. 

2  G.  E.  Curatulo.    Secrezione  Interna  delle  Ovale,  1896. 


CHAPTER    XXIV. 

URETHRITIS— URETHRITIS  COMPLICATED  BY  PROLAPSE 
OF  URETHRA— URETHRITIS  COMPLICATED  BY  SUB- 
URETHRAL ABSCESS— CYSTITIS— PYELITIS. 

URETHRITIS. 

Etiology  of  Urethritis. 

The  conditions  which  favor  and  excite  urethritis  are  the  same  as 
for  inHamniation  in  general.  The  disease  occurs  by  extension,  most 
frequently  from  gonorrhoeal,  least  frequently  from  syphilitic  vulvo- 
vaginitis. It  may  be  caused  by  the  bacillus  of  diphtheria,  the  strep- 
tococcus, the  staphylococcus,  the  bacillus  tuberculosis,  or  by  other 
bacteria  which  are  known  to  infect  the  genitalia.  Among  the  media 
of  infection  are:  the  unclean  catheter,  sound,  or  hand ;  an  unclean 
pessary,  masturbation,  and  coitus.  Among  the  favoring  conditions  are 
the  passage  of  urinary  calculi  and  irritation  from  new  growths. 

Pathology  and  Diagnosis  of  Urethritis. 

The  mucosa  as  exposed  by  the  cystoscope — Chapter  III. — is  swol- 
len and  red  from  distention  of  the  vessels,  and,  upon  instrumental 
examination,  may  bleed.  The  inflamed  urethral  glands  stand  out 
prominently  as  oval  yellow  spots,  and  in  the  anterior  part  of  the 
urethra  sometimes  give  forth  a  secretion  which  looks  like  pus,  but 
may  be  only  epithelial  debris.  The  tenderness  in  the  milder  infec- 
tions is  less  marked  than  in  the  gonorrhoeal  variety. 

Gonorrhoeal  infection  in  the  acute  form  is  intense  and  somewhat 
characteristic.  The  swollen  mucosa,  at  first  of  deep-red  color  and 
finally  covered  with  pus,  protrudes  through  the  meatus,  and  has  much 
the  appearance  of  an  inflamed,  prolapsed  anus.  It  is  excessively  sensi- 
tive to  touch,  and,  especially  when  touched  by  an  instrument,  is  apt  to 
bleed.  Burning  and  pain  on  urination  may  be  intense.  Microscopi- 
cal examination  of  the  pus  will  show  gonococci.  The  eversion  of  the 
meatus  usually  disappears  as  the  urethritis  subsides. 

Skene's  Glands. — The  urethral  glands  of  Skene  as  described  by 
himself  are,  in  this  connection,  of  great  pathological  significance.  They 
consist  of  two  glandular  tubules  situated  one  on  either  side  of  the 
urethrovaginal  wall.  Each  tubule  extends,  from  a  point  just  within 
the  meatus  urinarius,  parallel  to  the  urethra  to  a  distance  of  about 
five-eighths  of  an  inch.  The  tubules,  lined  with  columnar  epithelium, 
branch  into  the  muscularis  of  the  urethrovaginal  wall.  Wlien  the 
urethra  is  swollen  and  the  meatus  everted,  the  openings  of  the  tubules 

21  333 


334    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

appear  just  outside  the  urethra.    The  normally  placed  openings  are  seen 
on  either  side  by  separating  x\\&  labia  of  the  meatus  uriuarius. 

When  inflamed,  these  tubules  give  forth  upon  pressure  a  white 
serous  or  purulent  discharge.  The  mucous  membrane  around  their 
openings,  as  in  follicular  pharyngitis,  is  swollen,  thickened,  and  of  a 
bright  yellowish-gray  color,  or  the  orifices  may  be  surrounded  by  a 
granular  areola.  The  infection  involves  also  the  periglandular  struct- 
ures. The  urethrovaginal  wall  in  the  neighborhood  of  the  tubules 
usually  is  swollen  and  everted.  The  inflammation  is  generally  puru- 
lent, very  often  gonorrhoeal,  and  may  give  rise  to  a  free  discharge. 
Occlusion  of  the  tubules  by  adhesive  inflammation  and  the  consequent 
formation  of  retention-cysts  is  possible.  There  is  often  great  tender- 
ness on  pressure.  Chronic  infection,  as  a  rule,  gives  rise  to  little  or  no 
pain  on  urination.  Inflammation  in  these  glands,  until  described  by 
Skene,  had  been  mistaken  for  caruncle  of  the  urethra.  The  bright- 
red  areola  upon  the  swollen  and  thickened  mucous  membrane  about 
the  openings  of  the  tubules  closely  resembles  caruncle.  The  diifer- 
entiation  between  inflammation  of  Skene's  glands  and  caruncle  of  the 
urethra  will  become  apparent  on  examination  of  the  tabular  statement 
below. 

Inflammation  of  Skene's  glands.  Caruncle  of  tft£  Urethra. 

1.  Urination  not  usuaUy  painful.  1.  Urination  painful. 

2.  Two  protuberances  correspond  to  site  of        2.  Usually  only  one  protuberance  situated 
openings  of  tubules.  anywhere  in  the  circumference  of  the  meatus 

or  within  the  meatus,  but  usually  on  the  pos- 
terior wall. 

3.  Removal  of  protuberances  does  not  cure.       3.  Removal  cures. 

4.  Mouths  of  tubules  inflamed.  4.  Mouths  of  tubules  normal. 

The  gonococcus  may  become  intrenched  in  these  glands,  as  in 
the  glands  of  Bartholin,  and  from  time  to  time  furnish  infection  for 
recurrent  gonorrhoea.  Even  though  the  disease  may  have  disappeared 
from  the  external  surface,  reinfection  from  the  glands  may  occur 
repeatedly.  This  source  of  reinfection,  unless  carefully  sought,  is 
liable  to  be  overlooked.  If  the  urethral  glands  are  in  a  state  of  sup- 
puration, the  pus  may  be  stripped  out  of  them  by  pressure  of  the 
finger  and  a  stroking  motion  against  the  urethrovaginal  wall.  Drops 
of  pus  are  shown  issuing  from  the  ducts  on  digital  pressure  in  Figure 
149.  A  purulent  discharge  from  the  urethra  is  strong  clinical 
evidence  of  gonorrhoeal  infection.  Tubercular  infection  of  the  glands 
has  been  observed  repeatedly. 

Treatment  of  Urethritis. 

The  milder  non-gonorrhoeal  form,  if  not  complicated  by  cystitis, 
may  usually  be  cured  promptly  by  a  few  applications  made  at  inter- 
vals of  four  or  five  days  of  a  3  per  cent,  solution  of  silver  nitrate.  The 
application  is  made  by  an  applicator  wound  with  cotton,  through  a 
urethral  speculum.  Extreme  forcible  dilatation  of  the  urethra  has 
been  much  practised  for  the  relief  of  this  and  the  more  intense  forms 
of  urethritis,  and  often  has  given  prompt  and  pronounced  relief.  Per- 


URETHRITIS.  335 

manent  injury  to  the  urethra  and  consequent  incurable  incontinence 
of  urine  have  resulted,  however,  about  three  times  in  a  hundred  of 
such  dilatations.     The  safe  limit  of  dilatation  is  not  over  five-eigliths 


Figure  143. 


Figure  144. 


A 

1 

P^ 

V 

^mr 

Kv 

m 

,< 

^^ 

A     A 

Figure  145, 


Figure  146. 


Figure  143.— Normal  meatus  urinariu.s.  The  openings  of  the  ducts  leading  from  Skene's 
glands  are  hidden  just  within  the  meatus  in  a  line  connecting  the  letters  A,  A.  The  black  and 
white  dotted  line  indicates  the  direction  of  an  incision  by  which  the  meatus  may  be  laid  open, 
so  as  to  expose  the  openings  of  the  ducts. 

Figure  144. — Meatus  laid  open  by  a  vertical  incision  ;  the  openings  of  the  ducts  leading 
from  Skene's  glands  exposed.  They  are  represented  by  black  dots  on  a  line  drawn  between 
the  letters  A,  A. 

Figure  145.— Urethral  mucosa  dissected  out  and  laid  open  by  the  incision.  Two  fine  probes 
are  introduced  into  the  ducts  leading  from  Skene's  glands,  A,  A. 

Figure  146.— U,  cross-section  of  urethra  :  .-\,  A,  cross-section  of  Skene's  ducts. 

to  three-fourths  of  an  inch.  Emmet's  so-called  button-hole  operation, 
described  under  stricture  of  the  urethra,  answers  the  therapeutic 
indication  of  dilatation,  and  does  not  impair  the  retentive  power ;   it 


336    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

also  has  the  advantage  of  rendering  the  diseased  mucosa  accessible  to 
direct  local  treatment.  The  opening  may  at  any  time  be  closed  by 
interrupted  sutures  ;  but  inasmuch  as  there  is  usually  no  functional 
impairment  this  repair  seldom  is  called  for. 


Figure  147. 


FlGTJKE  148. 


Figure  149. 


Figure  150. 

1^ 

r^^^^ 

^ 

Figure  147. — A,  A,  the  ducts  leading  from  Skene's  glands  swollen  and  everted.  The  black 
dots  represent  the  openings. 

Figure  148.— Urethral  caruncle  at  one  side  of  the  meatus,  simulating  in  appearance  the 
swollen  and  everted  Skene's  duct.    Observe  the  absence  of  the  opening  of  a  duct. 

Figure  149. — Expression  of  pus  from  the  ducts  of  Skene's  glands. 

FiGimE  150. — A  large  hypodermic  syringe-needle  with  blunt  point  and  a  rubber  bulb 
attached.  This  is  intended  as  a  pipette,  by  means  of  which  may  be  Injected  into  Skene's  ducts 
medicinal  substances  for  treatment  of  infection. 

Gonorrhoeal  urethritis,  if  acute,  is  treated  first  by  a  single  applica- 
tion of  a  10  per  cent,  solution  of  silver  nitrate,  then  by  rest;  com- 
presses to  the  vulva,  saturated  with  lead  water  and  laudanum,  or 
sedative  suppositories  in  the  rectum,  may  give  relief.  If  the  irrita- 
tion is  very  great,  the  compress  may  be  saturated  with  a  5  per  cent, 
solution  of  cocaine  muriate.  The  medicinal  treatment  will  be  the  same 
as  for  gonorrhoea  in  the  male.     Urotropin  is  recommended  highly. 


URETHRITIS. 


337 


Chronic  inflammation  in  Skene's  glands,  especially  if  gonorrhoeal, 
usually  resists  all  conservative  measures.  If  it  does  not  yield  to  the 
application  of  nitrate  of  silver  fused  on  a  fine  probe,  or  to  injections 
of  disinfectants,  the  entire  length  of  the  tubules  should  be  laid  open 
on  the  vaginal  side,  using  a  probe  as  a  guide.  The  glandular  struct- 
ures are  then  to  be  destroyed  by  caustic  or  by  excision  with  scissors, 
and  the  surfaces  made  to  heal  by  granulation.  To  fuse  the  silver 
nitrate  on  the  probe,  let  the  salt  be  melted  in  a  small  receptacle  over 
a  spirit-lamp,  and  dip  the  end  of  the  probe  into  it  repeatedly  so  as  to 
coat  it  over  with  a  thin  layer  of  the  salt. 

Figure  151. 


Emmet's  button-hole  operation. 

Treatment  of  Urethral  Stricture. — The  inflammatory  process  may 
have  been  so  intense  as  to  produce  contracting  cicatricial  tissue  and 
consequent  stricture.  The  cause  of  this  uncommon  lesion  is  usually 
gonorrhoea  or  trauma.  The  treatment  is  dilatation  by  means  of 
graduated  sounds,  as  in  stricture  of  the  male  urethra.  Should  dilata- 
tion fail,  a  urethrovaginal  fistula  may  be  made  and  the  vaginal 
margins  sutured  to  the  urethral  margins  of  the  opening.  When  the 
edges  have  healed  securely,  the  fistula  may  be  closed  by  denudation 
on  the  vaginal  surface,  the  interrupted  silkworm  gut  sutures  being  so 
placed  as  to  give  ample  calibre  to  the  restored  urethra.  See  Figure 
151. 


338    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 


URETHRITIS  COMPLICATED  BY  PROLAPSE  OF  URETHRAL 

MUCOSA. 

Description. — Prolapse  of  the  urethral  mucosa  and  submucosa, 
with  complicating  urethritis,  has  been  described  by  Emmet.  The  pro- 
lapsed mucosa  projects  from  the  upper  or  lower  margin  of  the  meatus 
or  surrounds  the  outlet  of  the  urethra.     The  urethra  is  obstructed, 

Ftgube  152. 


Emmet's  operaciou  for  prolapse  of  the  urethra. 

and  as  the  obstruction  increases  there  is  frequent  or  constant  urethral 
tenesmus.  Finally  the  entire  urethral  mucosa  and  submucosa  may 
be  rolled  out  so  as  to  resemble  a  greatly  prolapsed  anus.  The 
urethral  canal  dilates,  and,  as  the  circulation  is  obstructed,  the  rolled- 


URETHRITIS  COMPLICATED  BY  SUBURETHRAL  ABSCESS.      339 

out  structures  become  oedematous.  Cystitis  and  iufection  of  the 
kidney  are  possible  results. 

When  the  prolapse  is  confined  to  the  upper  or  lower  wall  of  the 
urethra  and  the  outroUed  tissues  are  from  the  outlet  of  the  canal,  they 
resemble  hemorrhoids,  and  may,  as  in  the  operation  for  hemorrhoids, 
be  removed  by  ligature. 

When  the  prolapse  is  extensive  and  circular,  removal  in  a  mass  is 
prohibited,  first,  because  more  prolapsed  tissue  usually  follows  and 
promptly  takes  the  place  of  that  which  has  been  removed  ;  second, 
because  a  distressing  stricture  of  the  urethra  may  result.  Prolapse 
of  the  urethra  may  be  the  result  of  the  traumatisms  of  labor  or  other 
causes  and  may  have  primarily  at  least  no  inflammatory  history. 

Treatment  of  Prolapse   of  Urethral  Mucosa. 

The  treatment  of  extensive  prolapse  from  any  cause  is  to  return 
the  displaced  mucosa,  if  possible ;  and  if  relief  does  not  follow,  it  is 
well  to  make  a  small  vesicovaginal  fistula,  and  thereby  give  the 
urethra  perfect  rest.  If  this  measure  fails,  the  prolapse  may  be  cured 
permanently  by  making  what  Emmet  calls  a  button-hole  slit  in  the 
urethrovaginal  wall  and  drawing  through  this  the  excessive  mucosa 
and  cutting  it  away.  The  sutures  for  closure  of  the  opening  are 
introduced  before  the  excision.  During  the  placing  of  the  sutures  a 
sound  should  be  in  the  urethra.     Figure  152. 

URETHRITIS  COMPLICATED  BY  SUBURETHRAL  ABSCESS. 

Suburethral  Abscess  occurs  in  the  urethrovaginal  wall.  It  has 
been  described  by  Lawson  Tait  under  the  name  urethral  cyst.  The 
pathology  is  not  fully  explained.  In  the  limited  number  of  cases 
described,  the  sac  occupying  the  urethrovaginal  wall  varies  in  size 
from  that  of  a  walnut  to  that  of  a  hen's  egg,  and  communicates  with 
the  urethra  by  a  small  opening.  The  presence  of  this  sac  has  been 
explained  by  Tait  as  a  congenital  defect,  and  by  Kelly  as  a  retention- 
cyst  formed  by  inflammation  and  occlusion  of  Skene's  ducts  and  the 
subsequent  perforation  of  the  urethral  wall.  Inasmuch  as  Skene's 
ducts  are  possibly  the  remnants  of  Gaertner's  ducts — rudimentary 
Wolffian  ducts — both  the  congenital  and  cyst  theories  may  be  true. 

The  tumor  has  the  appearance  of  pronounced  cystocele,  is  well 
defined,  and  very  tender  to  the  touch.  Pus  and  ammoniacal  urine 
often  escape  from  it  through  the  urethra.  The  tenderness  is  so  great 
that  anaesthesia  usually  is  required  for  examination.  If  the  communi- 
cation with  the  urethra  is  exposed  by  a  urethral  speculum  and  pressure 
be  made  upon  the  sac,  one  may,  as  the  sac  is  reduced  in  size,  see  its 
contents  forced  into  the  urethra. 

Treatment  of  Suburethral  Abscess. 

The  treatment  is  to  dissect  out  the  sac-wall  and  close  the  wound 
with  interrupted  silkworm  gut  or  catgut  sutures.  These  sutures  at 
the  same  time  should   close  the  urethral  opening.     Complete    ana- 


340    INFECTIONS,   INFLAMMATIONS,  AND  ALLIED    DISORDERS 

tomical  and  symptomatic  cure  follows  this  operation.  If  the  sac  has 
ruptured,  it  may  be  drained  by  gauze  packing  held  in  place  by  a 
T-bandage   until  it  heals  by  granulation. 

CYSTITIS. 

In  pathology  and  symptoms,  inflammation  of  the  female  bladder 
differs  in  few  respects  from  that  of  the  male.  The  peculiar  sources 
of  infection,  the  relative  shortness  of  the  female  urethra,  and  the 
easy  access  to  the  bladder  through  the  vesicovaginal  wall,  however, 
give  to  the  etiology,  diagnosis,  and  treatment  a  clear  gynecological 
significance. 

When  the  diagnosis  of  cystitis  was  based  upon  the  presence  of  pus 
in  the  urine  and  painful  and  frequent  urination,  treatment  gave  less 
satisfaction  to  the  physician  and  less  relief  to  the  patient  than  that  of 
almost  any  other  inflammatory  disorder.  Now  these  symptoms, 
pyuria  and  painful  and  frequent  urination,  are  recognized  as  results 
not  only  of  inflammation  of  the  bladder,  but  also  of  a  variety  of  other 
lesions,  especially  lesions  of  the  ureter,  kidney,  and  urethra.  More- 
over, the  cystitis  itself,  which  often  is  thought  of  as  a  distinct  disease, 
now  is  relegated  almost  to  the  rank  of  a  symptom,  and  is  considered 
properly  in  its  relations  to  certain  deeper  lesions  w^hich  individually 
or  collectively  may  underlie  and  perpetuate  it  or  may  result  from  it. 
Within  a  single  decade  the  management  of  this  symptom  has  risen 
from  the  plane  of  empiricism  and  has  taken  its  place  upon  the 
scientific  basis  of  pathology.  This  change  has  come  about  chiefly  as 
the  result  of  two  causes  : 

Etiological  investigations,  especially  including  bacterial  causes. 

Improved  instrumentation  in  diagnosis  and  treatment. 

Etiology  of  Cystitis.^ 

In  addition  to  most  of  the  sources  of  infection  common  to  cystitis 
in  the  male,  the  female  bladder  is  more  subject  to  concurrent  infection 
from  the  same  causes  which  give  rise  to  infection  of  the  reproductive 
organs.  Susceptibility  is  increased  during  the  recurring  physiological 
congestion  of  menstruation,  and  especially  during  the  puerperal  state. 
Furthermore,  infection  may  spread  readily  from  the  reproductive  to 
the  urinary  organs.  Vulvitis,  for  example,  may  extend  to  the  urethra, 
bladder,  and  ureters.  Such  extension  to  the  urinary  organs,  however, 
is  retarded  somewhat  by  the  fact  that  the  urinary  tract  is  washed 
freely  by  a  downward  current  of  urine  and  by  the  further  fact  that 
the  urine,  being  acid,  is  hostile  to  the  culture  of  about  90  per  cent,  of 
pathogenic  bacteria. 

It  is  most  important  to  distinguish  clearly  the  predisposing  from 
the  exciting  causes. 

Predisposing  Causes. — Among  the  predisposing  causes  or  favor- 
ing conditions  are  : 

1.  Pathological  urine. 

2.  Retention  of  urine. 

1  Senn.    Transactions  American  Surgical  Association,  ]898.    Consulted. 


CYSTITIS.   *  341 

3.  Tumors. 

4.  Foreign  bodies,  especially  stone. 

5.  Trauma.     Rupture  of  pelvic  abscess  into  bladder. 

6.  Any  local  or  systemic  cause  of  congestion  or  blood-stasis. 

7.  Rheumatism  and  gout. 

Formerly  these  were  considered  the  essential  causes  of  cystitis. 

Exciting  Causes. — Vastly  predominating  at  least  among  the 
exciting  causes  are  the  pathological  bacteria  and  their  products.  The 
bacteria  most  frequently  found  are  : 

1.  Bacillus  coli  communis. 

2.  Gonococcus. 

3.  Bacillus  tuberculosis. 

The  bacteria  less  frequently  found  are : 

1.  Proteus  vulgaris,  Hauseri. 

2.  Staphylococci  pyogenes. 

3.  Streptococci  pyogenes. 

4.  Typhoid  bacillus. 

It  is  agreed  generally  that  the  gonococcus  and  bacillus  tuberculosis 
are  prone  to  attack  the  healthy  bladder,  and  that  they  require  little  if 
any  predisposing  causes.  On  the  other  hand  a  normal  bladder  is 
said  to  offer  much  resistance  to  the  other  bacteria — that  is,  they  do 
not  become  active  except  in  conjunction  with  definite  predisposing 
causes. 

Ammoniacal  urine  is  known  to  result  from  the  decomposing  action 
upon  urea  of  certain  bacteria,  notably  the  proteus  vulgaris.  The 
frequent  association  of  alkaline  ammoniacal  urine  with  cystitis  has 
given  rise  to  the  more  or  less  common  impression  that  the  disease 
depends  upon  the  irritating  action  of  urine  which  has  undergone 
ammoniacal  decomposition,  and  that  such  decomposition  is  associated 
necessarily  with  cystitis.  Johannes  Miller/  of  Wurtzburg,  was  the 
first  to  overthrow  this  idea.  He  showed  that  in  73  per  cent,  of  the 
cases  of  cystitis  the  urine  was  acid.  Soon  after  the  observations  of 
Miller,  Melchior^  reported  the  results  of  sixty-two  very  accurate 
observations.  He  found  that  ammoniacal  decomposition  was  only  a 
minor  phenomenon,  and  that  in  many  of  the  severest  forms  of  cystitis 
acid  urine  was  present  even  to  the  time  of  death.  Almost  all  investi- 
gators now  reach  the  uniform  result  that  the  bacillus  coli  communis, 
or  a  microbe  very  closely  related,  is  the  one  most  frequently  found  in 
cystitis.  Out  of  one  hundred  and  twenty  cases  collected  by  Rostoski 
this  germ  was  found  in  eighty.  Whenever  the  bacterium  coli  com- 
munis was  found  alone  the  urine  was  acid  ;  Avhenever  the  proteus 
vulgaris  was  found  it  was  alkaline.  Alkalinity  with  bacteria  coli 
communis  is  said  to  be  always  due  to  association  of  other  microbes. 

Instrumentation  in  Cystitis. 

Within  a  few  years  the  cystoscope  has  revolutionized  our  knowl- 
edge of  the  pathology,  diagnosis,  and  treatment,  not  only  of  cystitis, 
but  of  many  other  hitherto  more  obscure  urinary  disorders. 

'  Rostoski.    Deutsche  mediciiiische  Wochenschrift,  S.  235, 1898. 
2  Monatsberifht  aber  den  Gesamtleistuugen,  Heft  10. 


342    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

Formerly,  Avlien  the  principal  factors  in  etiology  were  stricture  of 
the  urethra,  foreign  bodies  in  the  bladder,  and,  in  the  male,  enlarge- 
ment of  the  prostate,  and  when  there  was  no  means  of  viewing  the 
mucosa,  the  finger  through  the  dilated  urethra  and  the  sound  were 
almost  the  only  means  of  exploring  the  bladder.  Digital  exploration 
with  its  attendant  dangers  was  then  common  practice.  As  late  as 
1883  Sir  Henry  Thompson,^  in  his  work  on  Digital  Exploration, 
reported  as  the  result  of  two  years'  observation  by  that  method  a  series 
of  over  thirty  cases  of  tumor  in  the  bladder  upon  which  he  had 
operated.  Most  significant  in  contrast  is  the  report  of  Alexander 
Stein/  two  years  earlier,  in  which  he  was  able  to  collect  from  all  the 
literature,  including  post-mortem  observations,  only  about  twenty 
cases. 

By  means  of  the  cystoscope  the  entire  interior  of  the  bladder  may 
be  brought  into  view  ;  foreign  bodies,  tumors,  and  other  pathological 
changes  may  be  recognized,  and  the  ureters  and  the  pelvis  of  the  kid- 
ney maybe  explored.  The  instrument  has  often  revealed  the  presence 
of  stones,  tumors,  and  ulcers  which  had  escaped  detection  by  the 
sound.  Numerous  cases  in  which  cystitis  is  of  only  secondary 
importance  to  other  associated  lesions,  such,  for  example,  as  tumors, 
tuberculous  ulcers,  and  piles,  or  hemorrhoids  of  the  bladder,  are  now 
observed  daily  by  the  cystoscope. 

Cystoscopy  is  also  of  great  value  in  preventing  blind  and  meddle- 
some treatment  for  a  class  of  cases  which  present  the  subjective  symp- 
toms of  cystitis,  but  in  which  inspection  fails  to  show  any  lesion 
whatever  of  the  bladder  mucosa. 

The  value  of  the  instrument  is  also  incalculable  when  only  limited 
areas  are  diseased  ;  for  example,  in  case  of  mild  inflammation  of  the 
trigone  and  in  fissure  at  the  neck  of  the  bladder.  Under  such  con- 
ditions the  operator,  instead  of  treating  the  entire  vesical  mncosa  by 
means  of  injections  more  or  less  strong,  may  direct  any  desired  applica- 
tion to  the  diseased  part  only. 

Pathology  and  Diagnosis  of  Cystitis.^ 

Cystitis,  in  the  first  place,  must  be  differentiated  from  simple  irri- 
tability of  the  bladder ;  a  condition  found  in  neurasthenic  subjects, 
the  diagnosis  and  treatment  of  which  are  usually  those  of  some  under- 
lying neurosis. 

The  attempt  will  not  be  made  to  differentiate  all  the  phases  and 
varieties  of  cystitis,  but  rather  to  outline  the  more  pronounced  types. 

In  the  beginning  of  cystitis  tlie  cystoscope  shows  the  blood-vessels 
to  1)0  defined  less  sharply  than  in  health.  Soon  the  normal  light  pink, 
almost  whitish,  color  of  the  mucosa  assumes  a  deeper  and  deeper  hue 
nntil  the  shai-p  demarcation  between  the  vessels  is  lost  and  the  whole 
surface  is  finally  of  a  uniform  deep  red.  The  epithelium  may  be  cast 
off  in  small  particles  from  circumscribed  areas  either  narrow  or  broad, 
and  the  surfaces  thus  exposed  may  take  on  a  granular  appearance. 
Finally  in  severe  cases  one  may  observe  pus  coagulation  and  excessive 

1  Belfield.    Am.  Gyn.  and  Obstet.  Journal,  Jan.,  1899.    Adaptation.  2  Ibid. 


CYSTITIS. 


343 


swelling  and  oedema  of  the  bladder-wall.     The  urine  in   such  cases 
contains  epithelial  detritus  and  pus-cells  in  large  quantities. 

Mixed  infection  and  other  complications  may  render  it  impossible 
to  distinguish  between  all  the  different  bacteriological  varieties  ;  it  is, 
however,  usually  possible  and  is  often  desirable  to  differentiate  the 
tubercular  from  other  varieties,  especially  from  the  gonorrhceal. 

Differentiation  of  Tubercitlae,  form  Gonorrhceal  Cystitis. 


Tubercular  cystitis. 

1.  Located  chiefly  about  the  trigone. 

2.  Inflammatory  reaction  zone  absent  or  not 
well  defined. 

3.  Tubercular  cystitis  not  common. 

4.  Characterized  by  presence  of  small  tuber- 
cles situated  about  the  trigone  and  ureteral 
orifices. 


5.  No  projecting  tufts  of  pus. 


6.  No  subperitoneal  extravasation  of  blood. 


7.  Bacillus  tuberculosis. 

8.  Often  extension  from  kidney  and  from  gen- 
eral tuberculosis. 

9.  History    of    tuberculosis.       Great    pain ; 
hsematuria. 


Gonorrhceal  cystitis. 

1.  Not  at  all  so  confined. 

2.  Clear  inflammatory  reaction  zone,  later 
changing  to  dull-brown  color. 

3.  Common. 

4.  Characterized  early  by  insular  areas  of  re- 
active inflammation,  with  healthy  or  nearly 
healthy  intermediate  mucosa.  Later  insuhir 
areas  may  become  confluent  and  extend  over 
the  whole  mucosa. 

5.  Projecting  tufts  of  gonorrhceal  pus  are  apt 
to  be  present.  In  chronic  stage  regions  of 
elevation  may  be  excavated  by  ulceration. 

6.  In  very  acute  stage  there  is  subperitoneal 
extravasation  of  blood. 

7.  Gonococcus. 

8.  Extension  from  vagina,  vulva,  or  urethra. 


9.  History  of  gonorrhoea.    Less  pain  ;  seldom 
blood  in  urine. 


The  Pathology  of  Tubercular  Cystitis  shows  : 

1.  At  first  small  grayish  tubercles  or  nodules  ;  later  larger  nodules 
and  deep  ragged  ulcers. 

2.  Trigone,  base,  and  posterior  wall  of  the  bladder  most  aifected  ; 
disease  may  extend  over  the  entire  bladder. 

3.  Bladder-wall  thickened  and  contracted. 

5.  Disease  may  end  fatally  in  few  months  or  may  continue  for 
years. 

The  Diagnosis  of  Tubercular  Cystitis  is  made  as  follows : 

1.  Non-gonorrhoeal  cystitis  in  a  phthisical  patient  is  usually 
tubercular. 

2.  Non-gonorrhoeal  cystitis  in  young  persons  is  usually  tubercidar. 

3.  Chronic  ulceration  of  the  bladder  is  often  tuberculous. 
Finding  of  the  bacillus  tuberculosis  in  the  urine  or  tissues  is  the 

only  absolute  diagnostic  sign  ;  to  obtain  tissues  for  microscopical  exam- 
ination, curette  the  ulcerated  .surfaces  through  the  endoscope.  The 
smegma  l^acillus,  which  has  the  same  minute  appearance  as  the 
tubercle  bacillus,  may  give  rise  to  confusion  in  diagnosis.  The 
former  are  decolorized  by  acid  more  than  the  latter. 

Classification  of  Cystitis. 

In  our  present  state  of  knowledge  of  the  subject  a  perfect  classi- 
fication is  impossible.     Numerous  classifications  have  been  proposed. 

Anatomical  Classification. — According  to  the  special  structures 
involved,  this  comprises  :  pericystitis,  paracystitis,  interstitial    cy.«titi?, 


344    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDEUS. 

and  endocystitis.  The  difficulty,  not  to  say  frequent  impossibility,  of 
separating'  these  varieties  one  from  the  other,  and  the  fact  that  two  or 
more  usually  coexist,  render  this  classification,  although  diagram- 
matically  attractive,  clinically  impossible.  There  are  no  sharp  lines 
of  demarcation  between  the  anatomical  forms. 

The  Pathological  Classification  includes  numerous  varieties, 
such  as  catarrhal,  suppurative,  ulcerative,  hemorrhagic,  exudative, 
exfoliative,  and  fissure  cystitis.  These,  however,  are  rather  phases 
and  possible  stages  than  distinct  varieties  of  the  inflammatory 
process. 

FiGTJEE   153. 


Conjoined  examination  of  tubercular  cystitis 

Bacteriological  Classification. — This  classification  might  com- 
prise as  many  forms  as  there  are  varieties  of  infective  microbes.  The 
principal  bacteria  have  been  mentioned.  This  classification,  although 
quite  plausible  in  the  laboratory,  is  often  impractical  at  the  bedside. 
It  is  possible,  however,  that  more  exact  knowledge  in  the  future  may 
give  to  it  the  status  of  a  scientific  working  guide. 

These  various  classifications,  however,  from  the  standpoint  of 
nomenclature  are  very  convenient.  Such  words  as  gonorrhoeal, 
acute,  chronic,  suppurative,  and  interstitial  are  useful  for  purposes 


PLATE  X 

Figure  1.     Cystitis  originating  in  tlie  Trigone  and  extending  to 
adjacent  surfaces.    Magnified. 


Figure  2.    Normal  Bladder  Mucosa.    Slightly  magnified. 


PLATE   Xr 

Figure  i.     Linear  Ulcer  of  Bladder  Mucosa.     Magnified. 


Figure  2.    Ulcerated  Patches  in  the  Trigone.     Slightly  magnified. 


CYSTITIS.  345 

of  description  and  to  designate  the  various  forms  and  phases  of  in- 
fective processes.  For  example,  we  should  use  the  word  endocystitis 
to  describe  not  a  distinct  lesion  independent  of  the  rest  of  the  bladder, 
but  rather  an  essential  part  of  an  inflammatory  process. 

Certain  so-called  clinical  and  pathological  forms  and  phases  of 
cystitis  may  be  designated  as  follows,  and  have  great  diagnostic 
significance. 

1.  Superficial  cystitis — catarrhal. 

2.  Suppurative  cystitis. 

3.  Ulcerative  cystitis. 

4.  Exudative  cystitis. 

5.  Exfoliative  cystitis. 

6.  Fissure  cystitis. 

7.  Foreign-body  cystitis. 

8.  Leucoplakia  cystitis. 

1.  Superficial  Cystitis. — A  large  proportion  of  the  cases  of  chronic 
inflammation  are  of  this  variety.  Generally  it  is  called  catarrhal 
cystitis  ;  the  term  should  be  restricted  to  superficial  infection  and  to 
cases  in  which  the  product  of  inflammation  comes  from  the  superficial 
epithelial  elements  of  the  bladder  mucosa.  The  disease  is  marked  by 
moderate  swelling,  redness,  and  exfoliation  of  epithelial  cells ;  the 
urine  contains  a  moderate  amount  of  pus  and  is  usually  acid.  Ero- 
sions, ulcerations,  and,  as  a  consequence,  more  abundant  suppuration 
may  follow — that  is,  cystitis,  originally  catarrhal,  may  become  dis- 
tinctly suppurative.  Great  alkalinity  of  the  urine  indicates  a  rather 
advanced  stage,  when  the  cystoscope  will  reveal  a  deposit  of  grayish- 
white  color  containing  mucopus. 

2.  Suppurative  Cystitis. — In  this  form  the  inflammation  may  have 
been  diffuse  from  the  beginning  and  have  involved  both  the  superficial 
and  deeper  structures  of  the  bladder- wall.  As  well  stated  by  Senn, 
the  microbic  infection  is  of  sufficient  intensity  to  destroy  the  proto- 
plasm of  the  pathological  products  of  the  inflammation  and  thus 
transform  the  leucocytes  and  epithelial  and  connective-tissue  cells  into 
pus-corpuscles.  The  urine  contains  an  abundance  of  epithelial  cells 
and  pus.  Ulcerative  processes  may  involve  the  deeper  structures, 
and  in  exceptional  cases  may  lead  to  perforation.  The  urine  is  acid, 
or,  if  ammoniacal,  may  be  so  from  decomposition  due  to  the  intercur- 
rence  of  microbes  other  than  those  which  produced  the  original  infec- 
tion. The  proteus  vulgaris  will  often  be  found  in  ammoniacal  urine. 
Suppurative  cystitis,  both  in  its  acute  and  chronic  stages,  is  prone  to 
invade  the  ureters  and  kidneys.  In  fact,  chronic  uncomplicated  su])- 
purative  cystitis  is  rare.  The  cystoscope  reveals  the  local  conditions 
as  already  described. 

3.  Ulcerative  Cystitis. — The  ulcerative  phase  of  cystitis  has  been 
mentioned  as  a  later  stage  of  the  catarrhal  or  suppurative  varieties. 
The  term  is  used  here  to  designate  that  variety  in  which  ulceration  is 
the  initial  or,  at  least,  a  very  early  factor.  The  infection,  as  described 
by  Senn,  appears  to  be  of  a  peculiar  kind  and  limited  in  extent.  The 
resulting  inflammation  leads  quickly  to  circumscribed  necrosis.  There 
is  at  first  a  single  circumscribed  ulcer,  the  so-called  "  simple  "  ulcer 


346    INFECTIONS,   INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

of  the   bladder   resembling   gastric   ulcer   and  the  round  duodenal 
ulcer. 

The  first  symptom  is  increased  desire  to  urinate ;  intermittent 
haematuria  then  appears.  The  ulcer  may  become  incrusted  with 
phosphates.  Fragments  of  the  deposit  break  oflP  now  and  then,  and 
may  be  passed  with  painful  paroxysms,  or  may  be  retained  to  serve  as 
nuclei  for  calculus  formation.  Finally  the  bladder  becomes  con- 
tracted and  the  mucous  membrane  extensively  ulcerated.  Ureteral 
and  renal  lesions  may  now  arise.  Ulcerative  cystitis,  like  gastric  and 
duodenal  ulcer,  is  found  quite  frequently  in  young  men,  less  fre- 
quently in  women.  There  are  usually  no  antecedent  or  attending 
predisposing  local  causes.  In  the  diagnosis  the  cystoscope  is  indis- 
pensable.^ 

4.  Exudative  Cystitis. — This  is  characterized  by  the  formation 
upon  the  bladder  mucosa  of  a  so-called  membrane  ;  hence  it  usually  is 
designated  by  the  rather  confusing  descriptive  terms,  "membranous," 
"diphtheritic,"  "croupous,"  or  "fibrinous."  The  exudative  mem- 
brane is  the  product  of  the  inflammation  ;  it  is  in  fact  apt  to  be  the 
product  of  extensive  necrotic  changes,  and  as  such  indicates  a  grave 
lesion.  There  may  be  extensive  destruction  even  in  the  musculature 
and  especially  in  the  deep  blood-vessels  and  lymphatics.  The  urine 
usually  is  alkaline.  The  disease  has  been  observed  chiefly  in  puer- 
peral women.  The  urine  contains  fibrinous  shreds  or  cast-ofl"  patches 
of  membrane.  Cystoscopic  examination  reveals  a  yellowish-white 
membranous  formation  which  often  may  be  picked  ofl"  by  means  of 
forceps  passed  through  the  cylindrical  cystoscope. 

5.  Exfoliative  Cystitis. — This  variety  is  analogous  to  so-called 
dissecting  metritis  and  dissecting  vaginitis.  The  infective  process  and 
inflammatory  reaction  are  most  virulent  and  intense,  and  result  in  the 
destruction  and  detachment  of  the  mucosa,  and  together  with  it  some- 
times of  the  muscular  layer  of  the  bladder ;  these  may  be  expelled  in 
fragments  with  the  urine  or  may  have  to  be  removed  from  the  bladder 
by  a  surgical  procedure.  It  is  the  most  grave  and  virulent  form  of 
cystitis,  and  is  apt  to  be  fatal.  The  conditions  are  like  those  of  exu- 
dative cystitis  intensified.  The  diagnosis  between  the  two  forms 
depends  upon  the  macroscopical  and  microscopical  character  of  the 
masses  removed  or  thrown  off  from  the  bladder.  The  disease  was 
described  early  and  fully  by  Boldt.^ 

Etiology. — Exfoliative  cystitis  is  associated  usually  with  one  or 
more  of  the  following  mechanical  conditions  : 

1.  Retroversion  of  the  gravid  uterus  in  50  per  cent,  of  cases. 

2.  Protracted  birth  in  25  to  30  per  cent,  of  cases. 

3.  Incarcerated  pelvic  tumors. 

4.  Retention  of  urine,  especially  in  puerperal  cases,  common. 

kSYMPTOMS. — 

1.  Membrane  expelled  in  urine. 

2.  Membrane  may  obstruct  the  urethra,  causing  retention. 

3.  Membrane  in  the  bladder  causes  vesical  tenesmus;  expulsion 

of  it  causes  pain  and  straining. 

1  Adaptation  from  Senn.  2  American  Journal  of  Obstetrics,  June,  1889. 


CYSTITIS. 


347 


4.  Death  may  occur  from  :    a,  sepsis ;  6,  uraemia ;    c,  pyelitis ; 
d,  peritonitis. 
6.  Fissure  Cystitis. — Fissure  cystitis  is  caused  by  infection  through 


FiGXJEE   154. 


stone  in  the  bladder,  a  cause  of  foreign-body  cystitis. 

a  traumatism  at  the  neck  of  the  bladder  or  in  the  trigone.  As  seen 
through  the  cystoscope,  the  fissure  is  covered  usually  by  a  brownish 
or  yellowish  exudate  surrounded  by  an  oedematous  area. 

FIGURE  155. 


Hairpin  in  the  bladder,  a  cause  of  foreign-body  cystitis. 

7.  Foreign-body  Cystitis. — Cystitis  caused  by  foreign  bodies  (Figures 
154  and  155)  varies  with  the  character  of  the  body  and  the  conditions 
of  infection.     A  smooth  body  may  be  tolerated  without  subjective 


348    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

symptoms.  A  rough  or  angular  substance  may  produce  trauma  and 
thus  open  the  way  to  any  form  of  infection.  The  foreign  body  is  the 
exciting  cause  and  opens  the  way  for  the  action  of  infecting  bacteria. 

8.  Leucoplakia  Cystitis.^ — This  affection  is  characterized  by  the 
appearance  of  grayish  small  circumscribed  areas  situated  usually  in  the 
trigone.  The  epithelium  has  undergone  changes  which  render  it 
opaque  and  which  have  been  likened  to  the  changes  of  keratitis. 
The  cystoscope  reveals  a  number  of  grayish-white  reHecting  spots  of 
a  diameter  approximating  one-fourth  inch.  These  spots  while  des- 
quamating are  below  the  level  of  the  surrounding  mucosa;  after 
desquamation  has  ceased  they  become  flush  with  the  mucosa.  A  most 
pronounced  subjective  symptom  is  an  intolerable  and  almost  constant 
desire  to  urinate.  Micturition  may  be  attempted  as  often  as  once  in 
fifteen  minutes  through  the  day,  and  almost  as  frequently  during  the 
night.  Leucoplakia  results  from  long-continued  chronic  areas  of 
inflammation;  it  may  be  the  starting-point  of  general  cystitis. 

Treatment  of  Cystitis.^ 

The  treatment  of  cystitis  falls  under  four  heads  : 

1.  Prophylactic. 

2.  Medicinal. 

3.  Topical. 

4.  Surgical. 

Prophylaxis.^ — Numerous  autopsies  upon  subjects  who  have  not 
suffered  from  cystitis  have  shown  a  hypersemic  state  of  the  bladder  so 
marked  that  it  must  have  been  of  long  duration,  yet  had  not  devel- 
oped to  the  extent  of  infection  and  inflammation.  The  explanation 
must  be  that  the  infective  element  had  not  been  present,  or  if  present 
had  not  become  active.  On  the  other  hand,  the  question  has  been 
raised,  and  usually  answered  in  the  negative,  whether  the  mere  pres- 
ence of  infective  microbes  alone,  bacillus  tuberculosis  and  gonococcus 
excepted,  can  easily  provoke  cystitis.  It  is  agreed  commonly  that 
infection  must  depend  usually  upon  :  first,  an  abnormal  condition  of 
the  soil  which  renders  it  susceptible ;  second,  upon  the  presence  of 
the  bacterial  exciting  cause.  A  twofold  indication  is  obvious  :  to  keep 
the  bladder  in  a  state  of  resistance,  and  to  avoid  the  introduction  of 
infective  material. 

Susceptibility  to  infection  may  result  from  either  systemic  or  local 
states.  The  systemic  conditions  are  often  the  result  of  faulty  elimi- 
nation and  consequent  defective  circulation.  Hepatic  and  cardie  dis- 
orders, kidney  insufficiency,  constipation,  gout,  lithsemia  and  cholsemia, 
anseraia,  diabetes,  rheumatism,  at  once  suggest  themselves  as  favoring 
conditions  calling  for  hygienic  and  medical  treatment,  for  judicious 
elimination  and  nutrition.  At  the  risk  of  seeming  to  advocate  routine 
measures,  one  may  suggest  the  value  of  mercurials  and  salines.  It  is 
clearly  essential  to  enforce  judicious  rules  for  food,  exercise,  and  sleep. 

The  introduction  of  the  catheter  under  the  sheet,  its  passage  with- 

«  Adaptation  from  Kolisher.  2  Adaptation  from  Kolisher. 

3  Kletsch.  Am.  Gyn.  and  Obstet.  Jour.,  1899.    Consulted. 


CYSTITIS.  349 

out  preparatory  disinfection  of  the  vulva,  the  careless  use  even  of  the 
aseptic  catheter  and  the  slight  traumatism  which  its  use  may  cause, 
and  the  almost  certain  ingress  of  septic  matter  through  such  trauma- 
tism, are  well  known  to  every  observing  physician.  But  unfortunately 
many  physicians,  although  cognizant  of  the  facts,  are  not  alive  to  the 
importance  of  them. 

The  possible  relations  of  parturition  to  cystitis  are  most  significant ; 
among  such  relations  are  those  which  arise  from  certain  pelvic  defects. 
For  example,  contraction  or  excessive  inclination  of  the  pelvis  may 
retard  or  obstruct  labor,  and  thereby  cause  prolonged  pressure  of  the 
child  upon  the  bladder,  giving  rise  to  conditions  full  of  danger. 

Gestation  in  a  retroliexed  uterus  finally  enlarges  the  uterus  until  it 
becomes  impacted  under  the  sacral  promontory ;  then  pressure  of  the 
cervix  upon  the  neck  of  the  bladder  produces  oedema,  forces  the  blad- 
der against  the  pubes,  prevents  complete  evacuation,  and  results  in  the 
retention  of  residual  urine.  This  urine  may  become  decomposed,  and 
is  then  a  most  favorable  culture-medium  for  bacteria.  If  there  be 
present  in  combination  the  three  elements,  cougestion,  decomposed 
residual  urine,  and  bacteria,  even  though  any  one  alone  might  be 
ineifective,  infection  is  almost  unavoidable.  The  necessity  for  prompt 
replacement  of  the  displaced  gravid  uterus,  therefore,  is  clear. 

Medical  Treatment. — The  medical  treatment  already  discussed 
as  a  part  of  the  prophylaxis  has,  especially  in  connection  with  other 
forms  of  treatment,  great  value.  The  principles  are  necessarily  those 
of  general  internal  medicine.  The  particular  indications  have  refer- 
ence to  the  use  of  such  drugs  as  may  change  the  quality  or  increase 
the  quantity  of  the  urine.  If  the  urine  is  strongly  acid  or  concen- 
trated, for  example,  it  should  be  diluted  by  the  free  drinking  of  fluids 
or  rendered  less  acid  by  the  use  of  alkalies ;  if  alkaline,  the  reaction 
may  be  modified  by  the  use  of  acids.  Lest  there  be  frequent  uri- 
nation during  the  night,  the  drinking  may  be  confined  largely  to 
the  morning  and  afternoon  hours.  To  secure  a  proper  degree  of 
acidity,  benzoic  acid,  alone  or  combined  with  borax  and  dissolved  in 
cinnamon-water,  is  a  classical  and  useful  remedy.  The  indication  to 
relieve  subjective  symptoms  is  twofold  :  first,  to  allay  suffering  and 
nervous  irritation  ;  and  second,  to  render  the  patient  less  intolerant 
of  topical  and  surgical  treatment. 

In  superficial  mild  cystitis,  with  frequent  urination  and  painful 
contractions  of  the  bladder,  prompt  relief  sometimes  follows  the  daily 
application  of  a  rectal  suppository  containing  two  or  three  grains  of 
ichthyol.  In  more  aggravated  cases  opium  may  be  substituted  for 
ichthyol.  To  secure  good  sleep  let  the  ichthyol  suppositories  be  used 
two  or  three  hours  before  bedtime,  and  followed  if  necessary  by  the 
opium  or  morphine  suppositories  at  bedtime. 

The  bowels  should  be  kept  normally  free  by  mild  laxatives. 
Drastic  cathartics  should  be  avoided.  Uva  ursi,  triticum  repens,  the 
benzoate  salts,  buchu,  eucalyptus,  and  many  other  time-honored  and 
classical  remedies  may  be  useful.  Urotropin  appears  to  be  the  most 
valuable  single  internal  remedy.  It  may  be  given  in  amounts  varying 
from  15  to  30  grains  daily.    The  writer  occasionally  has  been  gratified 

22 


350    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

at  the  disappearance  of  irritation  of  the  bladder  after  the  administra- 
tion three  times  a  day  for  a  number  of  weeks  of  calomel  in  doses  of  one- 
tenth  to  one-twentieth  of  a  grain  supplemented  by  the  free  use  of 
natural  or  artificial  mineral  waters  or  of  pure  water.  Rest,  especially 
in  the  acute  stage,  is  highly  important. 

Topical  Treatment. — The  washing  out  of  the  bladder  as  a  routine 
procedure  is  not  approved.    Irrigation,  however,  is  indicated  positively 

Figure  156. 


Washing  out  of  the  bladder.  The  irrigation  may  be  made  repeatedly  by  alternately  raising 
and  lowering  the  funnel ;  when  the  funnel  is  raised  the  fluid  flows  into  the  bladder,  when 
lowered  it  returns  to  the  funnel. 

when   necessary  for  the  removal  of  loose  irritating  shreds  or  other 
foreign  matter. 

The  superficial  forms  of  cystitis  respond  promptly  to  topical  treat- 
ment. If  the  cystitis  is  general  and  superficial,  two  ounces  of  a  10 
per  cent,  emulsion  of  iodoform  in  oleum  sesame  may  be  thrown  into 
the  bladder  with  a  hard-rubber  syringe.  If,  after  two  or  three  appli- 
cations of  the  emulsion,  there  is  sufficient  toleration,  four  ounces  of 
silver  nitrate  solution  may  be  injected  into  the  empty  bladder  and 


CYSTITIS.  351 

immediately  replaced  by  free  irrigation  of  normal  salt  solution.  The 
strength  of  the  silver  solution  should  vary  according  to  the  toleration 
of  it.  Begin  with  1  per  cent,  and  cautiously  increase  the  strength  if 
necessary  even  to  3  per  cent.  The  treatment  may  be  repeated  every 
two  or  three  days.  Oftentimes  two  or  three  mild  injections  will  eifect 
a  cure.  Vesical  injections  of  argyrol,  1  to  5  per  cent.,  are  non-irri- 
tating, effective,  and  may  be  substituted  for  the  silver  nitrate  solution 
to  advantage. 

In  many  cases  the  infection  is  localized,  and  when  localized  is 
confined  usually  to  the  trigone  or  inner  end  of  the  urethra.  The 
silver  application  should  then  be  applied  only  to  the  affected  part. 
It  may  be  used  in  solution  of  any  desired  strength  and  applied  by 
means  of  a  cotton  swab  introduced  through  the  cylindrical  cystoscope 
and  kept  within  bounds  by  the  immediate  instillation  of  salt  solution. 
Mild  infections  in  the  trigone  often  yield  completely  to  a  single  treat- 
ment. Fissure  cystitis  may  be  cured  promptly  and  permanently  by  this 
means,  but  aggravated  cases  sometimes  require  the  solid  stick.  Accom- 
panying urethritis  should  be  treated  simultaneously  with  the  cystitis. 

When  the  infection  has  caused  deep  infiltration  in  the  bladder- 
wall,  as  in  exudative  or  diphtheritic  cystitis,  the  treatment  is  to  be 
conducted  in  two  stages — first,  wash  out  the  bladder  to  remove  the 
shreds  and  other  putrid  material  ;  second,  apply  the  disinfectant.  In 
washing  out  the  bladder  use  small  quantities  of  fluid  and  repeat  until 
the  fluid  returns  clear ;  then  apply  the  disinfectant,  preferably  the 
silver  nitrate. 

If  the  secretion  on  the  bladder-wall  is  mucoid  in  character  and 
stringy,  it  is  better  to  use  normal  salt  solution  than  pure  water. 
When  the  bladder  is  so  painful  as  to  resist  all  efforts  at  treatment  it 
may  be  anaesthetized  with  10—20  c.c.  of  a  4  per  cent,  solution  of  anti- 
pyrin.  This  should  be  left  in  the  bladder  about  twenty  minutes.  If 
treatment  leaves  the  bladder  very  painful,  cupping  or  hot  applications 
over  the  bladder  or  opium  and  belladonna  suppositories  in  the  rectum 
are  indicated. 

Cystitis  with  granulations  or  ulcers  require  a  long  time  for  heal- 
ing ;  for  this  purpose  nothing  is  better  than  silver  nitrate  solution  or 
the  solid  stick. 

In  exfoliative  cystitis  any  systemic  cause  of  the  disturbance  should, 
if  possible,  be  removed.  The  membrane  when  it  becomes  gangrenous 
should  be  taken  away  by  means  of  forceps.  A  permanent  catheter 
then  should  be  inserted  both  for  protection  to  the  bladder  from  the 
results  of  distention  and  for  the  injection  of  antiseptic  solutions.  In 
these  cases  the  systemic  condition  is  grave  and  should  be  treated 
accordingly. 

Surgical  Treatment. — The  surgical  procedures  in  the  treatment 
of  cystitis  are  as  follows  : 

1.  Dilatation  of  the  urethra. 

2.  Vaginal  cystotomy,  also  called  colpocystotomy. 

3.  Curettage  of  the  bladder. 

4.  Lithotrity. 

,5.  Extra  vesical  operations. 


352    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

1.  Dilatation  of  the  Urethra. — The  indications  for  this  operation 
are  as  follows : 

A.  To  cure  localized  cystitis  in  the  regionof  the  trigone,  commonly 
called  trigonitis,  and  fissure  at  the  neck,  called  fissure  cystitis.  The 
mode  of  treatment  in  fissure  cystitis  is  doubtless  similar  to  that  of 
anal  fissure  by  dilatation  of  the  sphincter  ani  muscle. 

B.  To  enable  the  operator  to  see  and  treat  surgically  or  topically 
vesical  ulcers,  vesical  hemorrhoids,  small  growths,  and  other  affections 
of  the  bladder,  and  to  permit  the  crushing  of  stone. 

The  dilatation  is  made  by  means  of  the  urethral  dilator,  Figure  30. 
In  passing  the  instrument  one  should  note  the  extreme  natural 
diameter  of  the  urethra  and  then  limit  the  dilatation  to  about  twice 
this  diameter.  Further  stretching  is  apt  to  rupture  the  urethro- 
vaginal wall,  and  may  cause  permanent  incontinence  of  urine.  A 
cystoscope  five-eighths  of  an  inch  in  diameter.  Chapter  III.,  meas- 
ures the  extreme  safe  distention  of  the  average  urethra.  Exceptional 
cases  may  arise  in  which  this  amount  of  dilatation  could  safely  be  in- 
creased or  in  which  it  might  be  dangerous.  Whatever  stretching  can 
be  done  without  tearing  is  usually  safe.  The  dilatation  may  be 
started  with  the  conical  dilator,  and  completed  with  the  cystoscope. 

2.  Vaginal  Cystotomy. — This  operation,  Figure  150,  has  for  its 
object  the  formation  of  an  artificial  vesicovaginal  fistula.  It  opens 
the  way  to  intravesical  topical  treatments  and  operations.  Through 
the  fistula  tumors  may  be  removed  and  diseased  surfaces  cauterized 
and  curetted.  In  chronic  cases  of  great,  long-continued,  and  unre- 
lieved suffering  colpocystotomy  has,  by  giving  the  bladder  complete 
rest,  furnished  immediate  and  unspeakable  relief.  The  operation  may 
be  palliative  or  curative.  In  a  certain  proportion  of  cases  the  disease 
in  the  bladder  and  upper  zones  of  the  urinary  tract  is  so  extensive 
that  the  operation  can  only  be  palliative — that  is,  an  anatomical  cure 
is  sometimes  impossible.  In  some  of  these  cases  the  bladder  is  con- 
tracted permanently  to  the  capacity  of  perhaps  one-half  ounce.  No 
one  would  think  of  making  a  secondary  operation  for  the  closing  of 
the  fistula  under  such  conditions.  In  many  other  cases  the  artificial 
opening  may  be  only  temporary.  It  gives  the  best  opportunity  for 
direct  local  treatment  to  diseased  parts  of  the  bladder,  and  for  a  most 
effective  vesical  douche,  which  can  be  thrown  in  through  the  urethra 
and  allowed  to  flow  out  through  the  fistula  and  vagina.  Very  many 
cases  of  otherwise  intractable  chronic  cystitis  have  been  cured  by  this 
method  Avith  subsequent  closure  of  the  fistula,  and  the  cures,  if  not 
anatomically  complete,  were  at  least  symptomatically  satisfactory. 
In  some  cases  the  much  contracted  bladder  even  may  resume  its 
physiological  calibre.  The  operation  of  vaginal  cystotomy  is  the  de- 
vice of  T.  A.  Emmet. 

Operation. — The  patient  is  preferably  in  Sims'  position,  with  the 
anterior  vaginal  wall  exposed  by  Sims'  speculum.  A  large  sound  is 
introduced  through  the  urethra,  and  its  point  pressed  against  the 
vesical  mucosa  in  the  middle  of  the  long  axis  of  the  vesicovaginal 
septum.  An  incision  is  now  made  upon  the  sound  through  the  septum 
with    the   knife   or  scissors.     The  point  of  the  sound  then  will  pass 


CYSTITIS. 


353 


through  into  the  vagina.  The  opening  thus  made  is  enlarged  so  as  to 
extend  one  inch  in  the  median  line  of  the  long  axis  of  the  vesico- 
vaginal septum.  Its  upper  end  will  be  about  one-half  inch  from  the 
anterior  wall  of  the  cervix  uteri,  and  its  lower  end  the  same  distance 
from  the  neck  of  the  bladder.  The  margins  of  the  vesical  and  vagi- 
nal mucosa  then  are  united  by  fine  interrupted  catgut  sutures. 


Figure  157. 


Vaginal  cystotomy.  A  dilator  is  passed  through  the  urethra  iuto  the  bladder,  and  the 
blades  of  it  are  pressed  against  the  vesicovaginal  septum  at  a  point  in  the  median  line  mid- 
way between  the  uterus  and  urethra,  and  separated.  The  vesicovaginal  septum  is  incised  by 
means  of  the  scalpel  or  pointed  scissors,  which  are  forced  through  the  septum  between  the 
blades  of  the  dilator.  The  point  for  incision  is  determined  by  the  position  of  the  dilator,  and 
easily  can  be  telt  by  means  of  the  index-finger  in  the  vagina.  In  the  lower  part  of  the  Figure 
the  dilator  and  scissors  are  shown  comDlete,  and  in  the  position  in  which  they  are  when  the 
incision  is  made. 

The  accompanying  illustration  shows  a  device  which  renders  the 
operation  both  precise  and  simple ;  it  consists  in  the  introduction 
of  a  small  uterine  dilator  instead  of  the  sound  mentioned  above, 
through  the  urethra  into  the  bladder.  The  curved  blades  of  this 
dilator  are  turned  toward  the  vaginal  Avail,  the  points  of  the  blades 


354    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

are  pressed  against  the  vesicovaginal  septum  in  the  median  line — that 
is,  on  a  line  through  which  the  bladder  is  to  be  opened.  The  blades 
of  the  dilator  are  now  slightly  separated,  and  the  septum,  being  thus 
fixed,  is  incised  between  tlie  blades,  as  shown  in  the  illustration.  The 
incision  may  be  made  by  the  scalpel  or  scissors  with  accuracy  and 
without  danger  of  wounding  the  opposite  wall  of  the  bladder. 

In  some  of  the  less  severe  cases  sufficient  improvement  takes  place 
in  a  few  weeks  to  permit  the  closure  of  the  fistula,  with  permanent 
relief. 

In  the  more  chronic  cases  in  w^hich  the  bladder-walls  are  much 
thickened,  deeply  infected,  disorganized,  and  contracted,  and  particu- 
larly wdien  the  cystitis  is  complicated  with  pyelitis  and  nephritis,  the 
fistula  should  remain  open,  for  its  closure  will  be  followed  inevitably 
by  relapse. 

If  cystitis  be  complicated  by  stone  in  the  bladder,  the  treatment 
may  well  be  an  artificial  vesicovaginal  fistula  (colpocystotomy),  instead 
of  a  crushing  operation  through  the  urethra.  The  fistula  is  preferred 
for  two  reasons :  first,  the  crashing  operation  may  involve  an  objec- 
tionable degree  of  dilatation  of  the  urethra  ;  second,  the  fistula  is  use- 
ful as  a  means  of  drainage  for  the  cure  of  the  cystitis.  Colpocystotomy 
may  be  indicated  further  for  the  removal  of  foreign  bodies ;  it  also 
furnishes  an  opening  for  the  cauterization  or  curettage  of  ulcers. 

3.  Curettage  of  the  Bladder  may  be  done  through  the  tubular  cys- 
toscope,  but  better  through  an  artificial  vesicovaginal  fistula.  It  is 
indicated  in  indolent  ulcers,  especially  those  of  tubercular  origin. 

4.  Lithotrity  and  Lithotomy. — A  stone  in  the  bladder  may  be 
crushed  through  the  urethra  or  removed  through  an  artificial  vesico- 
vaginal fistula.  A  small  stone  or  other  foreign  body  may  be  removed 
entire  through  the  dilated  urethra.  Prompt  relief  "from  cystitis 
usually  follows. 

5.  Extravesical  Operations. — Parametritic,  perimetritic,  or  tubal 
abscess  may  by  rupture  into  the  bladder  cause  cystitis.  Incision, 
evacuation,  and  drainage  of  the  pus-cavity,  or  removal  of  the  pus-sac, 
is  followed  usually  by  prompt  cure. 

As  a  final  stage  in  the  treatment  of  cystitis,  the  bladder  if  con- 
tracted may  often  be  made  to  return  to  its  normal  size  by  methodical 
distention  w^ith  increasing  quantities  of  salt  salution  ;  but  this  should 
be  undertaken  only  after  the  cystitis  has  been  cured  and  the  patient 
is  free  from  the  dangers  of  recurrence. 

Summary. — 1.  The  conditions  which  formerly  were  considered 
the  prime  causes  of  cystitis  are  now  recognized  only  as  predisposing 
causes. 

2.  The  recognition  and  appreciation  of  pathogenic  bacteria  as  the 
exciting  causes  of  cystitis  are  essential  to  a  scientific  understanding  of 
the  pathology,  etiology,  and  treatment. 

3.  Alkalinity  of  urine  depends  upon  the  action  of  certain  bacteria, 
notably  the  proteus  vulgaris,  in  the  decomposition  of  urea.  The 
bacillus  coli  communis,  which  is  one  of  the  most  frequent  causes  of 
cystitis,  is  one  of  a  class  which  does  not  decompose  urea  and  therefore 
does  not  produce  ammoniacal  urine.     Contrary  to  the  older  opinion, 


CYSTITIS.  355 

alkalinity  is  not  the  rule  in  cystitis  ;  on  the  contrary,  in  the  majority  of 
cases  the  urine  remains  acid.  Alkalinity  if  present  is  the  work  of  other 
microbes  secondarily  introduced. 

4.  The  classical  symptoms  of  vesical  pain,  frequent  urination,  and 
pus  in  the  urine  are  wholly  inadequate  as  a  basis  for  the  diagnosis  of 
cystitis.  Moreover,  the  condition  called  cystitis  has  ceased  to  rank  as 
a  distinct  disease,  and  should  be  regarded  only  as  a  symptom.  The 
mere  recognition  of  the  fact  that  cystitis  exists  is  not  a  diagnosis ; 
a  fact  is  not  a  diagnosis.  Indeed,  the  recognition  of  cystitis  may  by 
contrast  with  the  recognition  of  its  complications  be  of  very  minor 
importance. 

5.  The  diagnosis  must  comprehend  not  only  the  presence  of  infec- 
tion in  the  bladder,  but,  what  is  more  important,  it  must  embrace 
the  source,  routes,  type,  complications,  and  variety  of  the  associated 
inflammatory  lesions.  Uncomplicated  inflammation  of  the  bladder  is 
rare. 

6.  The  endoscope  and  cystoscope  alone  can  open  the  way  to  effi- 
cient exploration  and  diagnosis,  alone  can  define  the  indications  for 
topical  or  surgical  treatment;  what  is  more  essential  still,  they  alone 
can  prepare  the  way  for  the  examiner  to  distinguish  between  cystitis 
and  a  wide  variety  of  other  affections  of  the  bladder,  urethra,  ureter, 
and  kidney.  One  is  astounded  at  the  revelations  of  the  cystoscope  in 
the  recognition  of  most  important  lesions  which  must  otherwise  escape 
notice. 

7.  The  washing  out  of  the  bladder  as  a  routine  measure  is  not 
approved.  The  injection  of  disinfectants  is  indicated  only  in  general 
or  nearly  general  cystitis.  For  localized  cystitis  direct  applications 
to  the  part  affected  should  be  made  through  the  endoscope. 

8.  Dilatation  of  the  urethra  is  indicated  for  localized  cystitis  at  or 
near  the  neck  of  the  bladder.  The  efficiency  of  the  procedure  for 
su(;h  localized  cystitis  has  given  it  an  undeserved  recognition  in  the 
treatment  of  general  cystitis  which  under  cystoscopy  it  cannot  now 
retain. 

9.  The  most  valuable  disinfecting  topical  application  in  cystitis  is 
nitrate  of  silver  or  argyrol. 

PYELITIS  AND  NEPHRITIS. 

This  topic  has  a  special  gynecological  significance  in  the  matter  of 
diagnosis  and  treatment  by  means  of  the  cystoscope  and  the  ureteral 
catheter,  which  have  been  described  in  Chapter  III.  The  ureteral 
catheter  is  introduced  into  the  ureter  through  the  cystoscope.  By 
this  means  one  may  wash  out  the  urinary  tract  u])  to  and  including 
the  pelvis  of  the  kidney  ;  as  a  result  of  this  treatment  apparent  cures 
in  cases  of  hydro-ureter  and  pyo-ureter  have  been  recorded. 

To  wash  out  the  ureter  the  patient  is  placed  in  the  knee-breast 
position ;  the  ureteral  catheter,  with  a  short  ])iece  of  rubber  tubing 
attached,  filled  with  a  sterilized  boric-acid  solution,  and  clamped  to 
keep  the  solution  from  running  out,  is  passed  through  the  cystoscope 
into  the  ureter  and  the  cystoscope  withdrawn.     A  sterilized    glass 


356    INFECTIONS,  INFLAMMATIONS,  AND  ALLIED  DISORDERS. 

funnel,  with  an  attached  rubber  tube  eighteen  inches  long,  is  filled 
with  the  irrigating  solution,  and  the  two  rubber  tubes  are  connected 
by  a  small  glass  tube  with  a  point  sufficiently  fine  to  fit  into  the  tube 
on  the  catheter.  By  raising  the  funnel  above  the  level  of  the  body 
the  fluid  is  made  to  flow  through  the  ureter  into  the  pelvis  of  the 
kidney.  When  the  funnel  is  dropped  below  the  level  of  the  body  the 
fluid  returns  ;  thus,  by  alternately  raising  and  lowering  the  funnel,  the 
fluid  is  made  repeatedly  to  flow  back  and  forth  and  to  wash  out  the 
ureter  and  pelvis  of  the  kidney.  The  fluid  may,  if  desired,  be 
changed  one  or  more  times  during  the  treatment.  The  apparatus  is 
similar  to  that  shown  in  Figure  157. 

Purulent  or  other  accumulations  in  the  ureter  should  be  permitted 
to  run  out  through  the  catheter  before  the  washing  out. 

The  practical  value  of  the  ureteral  catheter  as  a  therapeutic  agent 
remains  to  be  estimated.  The  attempt  to  cure  chronic  infection  in  the 
uterus,  nose,  throat,  and  other  mucous  cavities  by  washing  them  out 
with  various  fluid  has  generally  not  been  followed  with  great  success. 
It  is  probable  that  the  ureter  and  pelvis  of  the  kidney  will  not  be  an 
exception  to  the  rule.  Kelly  puts  forth  a  word  of  wise  precaution  on 
the  urgency  of  making  all  ureteral  manipulations  with  extreme  gentle- 
ness. The  catheter  should  never  be  pushed  up  higher  than  it  will 
pass  readily,  for  such  force  would  injure  the  mucosa  and  might  be 
followed  by  infection. 


PART  III. 

TUMORS,  TUBAL  PREGNANCY,  MALFOR- 
MATIONS. 


CHAPTEE    XXV. 

TUMORS  OF  THE  VULVA  AND  VAGINA. 

Varix.  Fibromyoma. 

Hseiiiatoina.  Lipoma. 

Elephantiasis.  Lupus. 

Papilloma.  Enchondroma. 

Carcinoma.  Neuroma. 

Sarcoma.  Cysts. 

VARIX. 

Varix  is  not  a  neoplasm,  but  an  aggregation  of  dilated  or  varicose 
veins  in  the  erectile  tissue  of  the  bulbi  vaginae.  The  varicose  state  is 
caused  by  obstruction  to  the  circulation.  This  obstruction  arises  from 
direct  pressure  upon  the  venous  trunks  by  the  gravid  uterus  or  may 
arise  from  pressure  exerted  by  tumors  or  inflammatory  exudates. 
Habitual  constipation,  portal  obstruction,  and  visceral  disease  may 
underlie  and  perpetuate  the  disorder ;  it  belongs  rather  to  advanced 
than  ta  early  life. 

The  tumor  is  oval,  globular,  or  serpentine,  may  grow  to  the  size 
of  a  child's  head,  is  irregular  in  form,  of  dark -blue  color,  and  tempo- 
rarily disappears  on  pressure.  The  chief  subjective  symptoms  are 
pruritus  and,  on  walking  or  standing,  a  sensation  of  fulness  and 
weight.  Rupture  of  the  distended  veins,  spontaneous  or  traumatic, 
may  occur  during  parturition,  and  if  external  may  cause  dangerous, 
even  fatal,  hemorrhage.  Rupture  into  the  tissue  of  the  mass  gives 
rise  to  an  accumulation  of  blood  called  hsematoma. 

Treatment  of  Varix. 

The  treatment  includes  mechanical  support  of  the  uterus,  if  dis- 
placed, regulation  of  the  bowels,  removal  of  waist  constriction,  the 
application  to  the  varix  of  a  pad  held  in  place  by  a  T-bandage,  the 
use  of  astringent  lotions,  and,  especially  during  pregnancy,  frequent 
rest.  The  radical  surgical  treatment  is  the  same  as  would  be  indicated 
by  the  general  principles  of  surgery  for  varix  in  any  other  part. 

357 


358  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

HEMATOMA. 

Hsematoma,  a  not  uncommon  result  of  varix,  is  an  extravasation 
of  blood,  not  a  new  growth.  The  causes  have  been  indicated  in  the 
foregoing  paragraphs  on  varix,  and  in  Chapter  XXXIX.,  on  Trau- 
matisms. The  tumor  may  develop  rapidly  or  slowly  even  to  the  size 
of  an  orange,  is  commonly  unilateral,  globular,  elastic,  and  of  a  violet 
color.  It  is  distinguished  from  pudendal  hernia  by  the  absence  of 
impulse  on  coughing  and  by  non-reduction  on  taxis ;  it  may  termi- 
nate by  absorption  or  by  suppuration,  or  the  blood-clot  may  become 
encysted.  The  treatment  in  the  early  stage  is  to  arrest  bleeding  by 
means  of  pressure  and  the  ice-bag.  If  an  abscess  develops,  it  should 
be  opened  freely  and  drained.  A  cyst- wall,  if  formed,  should  be  dis- 
sected out  and  the  wound  closed  by  deep  sutures. 

ELEPHANTIASIS— PACHYDERMIA. 

This  disease,  primarily  a  chronic  recurring  lymphangitis,  may  be 
associated  with  hyperplasia  of  the  connective  tissue,  skin,  mucous 
membrane,  and  epidermis  of  the  vulva.  The  whole  process  results  in 
the  formation  of  a  tumor,  sometimes  of  large  size,  and  most  frequent 
between  the  years  of  puberty  and  the  menopause.  It  is  rare  in  tem- 
perate, common  in  tropical  climates,  and  epidemic  in  certain  low- 
lying  countries  along  seacoasts  and  in  the  islands  of  the  tropics.  An 
organism  called  the  jilaria  sanguinis  hominis  is  found  early  in  the  dis- 
ease in  the  lymph-vessels  of  the  affected  part,  and  is  the  exciting 
cause ;  it  may  not  be  found  later,  for  the  vessels  are  blocked  by 
fibrous  deposit.^  The  tumor  may  involve  the  whole  or  a  part  of  the 
vulva,  most  frequently  the  two  labia  majora,  less  frequently  the 
clitoris,  and  least  frequently  the  nymphse. 

The  growth,  when  large,  is  apt  to  be  quite  pendulous.  The  surface 
may  be  smooth,  rough,  fissured,  warty,  or  ulcerated.  The  tumor, 
especially  if  ulcerated,  gives  forth  a  sero-albuminous  exudate,  which 
may  be  so  profuse  as  to  demand  frequent  change  of  clothing.  Ulcera- 
tion is  common  as  the  result  of  friction.  Cases  of  twenty  years'  dura- 
tion have  been  recorded.  The  enlarged  labia  may  reach  the  enormous 
weight  of  fifty  pounds.  Both  labia  are  involved  simultaneously.  The 
inguinal  glands  on  both  sides  are  enlarged.  Chyluria  is  a  frequent 
complication.  The  disease  does  not  directly  impair  the  general  health ; 
it  is,  however,  disabling  from  its  mechanical  interference  with  urina- 
tion, walking,  and  coitus.  Other  diseases  of  the  vulva  (so-called  false 
elephantiasis)  of  entirely  different  character,  such  as  papilloma,  may 
easily  be  mistaken  for  elephantiasis. 

The  Differential  Diagnosis  of  Elephantiasis. 

The  differential  diagnosis  from  papilloma,  carcinoma,  sarcoma, 
fibroma,  and  lipoma  depends  upon  the  clinical  history  as  outlined 
in  the  foregoing  paragraphs  and  upon  the  microscopical  finding.  Un- 
like elephantiasis,  all  these  growths  are  free  from  any  induration  of 

1  Roberts'  Gynecological  Pathology,  Anatomy,  and  Histology. 


TUMORS  OF  THE   VULVA   AND    VAGINA. 


359 


the  surrounding  skin.  Lupus  presents  more  extensive  ulcerations, 
deeper  induration,  darker  color,  and  has  for  its  essential  factor  the 
tubercle  bacillus. 

Treatment  of  Elephantiasis. 

The  treatment  is  excision.     The  numerous  dilated  lymph-channels 
increase  the  danger  of  septic  absorption,  and  in  the  operation  render 

FiorRE  ].58. 


Elephantiasis  of  vulva. 


the  most  extreme  asepsis  imperative.     The  operation  is  similar  to  that 
described  for  kraurosis  and  pruritus  vulvae,  Figure  81. 


PAPILLOMATA,  CONDYLOMATA,  OR  WARTS. 

Warty  growths  are  epithelial  in  type  and  are  characterized  by 
hypertrophy  of  the  papillae  of  the  skin  or  mucous  membrane,  increase 
of  connective  tissue,  and  thickening  of  the  epithelial  covering.  They 
are  divided  into  three  classes : 

1.  Non-specific — simple  papillomata — ordinary  warts. 


360  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

2.  Gonorrhoeal — condylomata  acuminata — pointed  condylomata, 

specific  vegetations  or  venereal  warts. 

3.  Syphilitic — flat  condylomata. 

1.  Non-specific,  Simple  Papillomata,  or  ordinary  warts,  are 
found  not  uncommonly  on  the  mons  veneris,  less  frequently  on  the 
labia.  They  are  of  unknown  origin,  usually  of  dark-brown  color, 
are  not  deeply  divided,  may  have  a  broad  base  or  may  be  peduncu- 
lated, and  are  not  apt  to  coalesce  into  large,  compact  masses. 

The  Treatment  is  excision  with  the  sharp  curette  and  cauterization 
of  the  base. 

Figure  159. 


fm 

JiHP"xr^ 

Jj^L 

.^y'-%»y^^M 

^HRpM^' 

V?3<^^H 

^^^^^Kr  \ 

^^^1 

ml 

-^k^W%"'      il 

fW^r 

^^•f^^"^! 

!> 

^ 

'  >?S^ 

p 

Simple  warty  vegetations  of  the  vulva. 

Gonorrhoeal  Warts — that  is,  warts  associated  with  gonorrhoea — 
are  found  on  the  vulva,  vagina,  cervix  uteri,  perineum,  and  about 
the  anus.  These  warts  occur  singly  in  groups,  or  in  cauliflower-like 
masses.  The  growths  may  be  so  large  as  to  interfere  with  coitus, 
urination,  or  defecation  ;  they  present  a  surface  which  is  soft,  moist, 
of  bluish  color,  and  divided  into  small  nodules  with  pointed  ends  like 
a  cock's  comb.  The  growth  occurs  during  pregnancy,  is  rapid,  but  may 
disappear  promptly  after  labor.  There  is  usually  an  associated  fetid 
vaginitis.     The  question  has  been  raised  whether  this  form  of  condy- 


PLATE  XII 


Enormous  warty  developments  about  the  vulva.  These  growths  were  so  extensive 
that  after  the  removal  of  them  it  was  impossible  to  draw  the  skin  over  the  exposed  surfaces, 
and  recourse,  therefore,  was  had  to  the  device  set  forth  in  the  plastic  operation  described 
in  the  following  Plates.  Author's  operation.  (Surgery,  Gynecology^  and  Obstetrics, 
June.  1906.) 


PLATE  XIII 


In  order  to  cover  the  exposed  surfaces  made  by  the  removal  of  the  growth  (Plate  XII), 
deep  lateral  incisions  are  made,  as  shown  in  the  upper  figure  by  the  dotted  lines  A  B,  A  C, 
D  E,  F  E.  The  space  included  in  the  triangles  ABC  and  D  E  F  are  slid  inward  toward 
the  vulva  and  the  wounds  are  closed,  as  shown  in  the  lower  figure.  The  same  device  is 
useful  also  in  closure  of  the  conipletely  lacerated  perineum,  when,  as  sometimes  occurs, 
so  much  tissue  has  been  destroyed  as  to  prevent  easy  approximation. 


TUMORS  OF  THE   VULVA  AND    VAGINA.  361 

lorua  may  not  occur  independently  of  the  gonococcus,  but  the  clini- 
cal evidence,  including  the  results  of  bacteriological  studies,  strongly 
points  to  at  least  a  coexistent  gonorrhcea.  The  part  played  by  the 
gonococcus,  except  as  a  predisposing  cause,  is  doubtful. 

The  Treatment  includes,  first,  thorough  cleansing  and  disinfection 
of  the  diseased  region ;  second,  removal  of  the  so-called  vegeta- 
tion with  scissors,  and  cauterization  of  the  base ;  third,  antiseptic 
dressing  and  washes  until  the  parts  have  healed.  The  danger  of 
puerperal  sepsis  and  ophthalmia  of  the  newborn  infant  strongly  sug- 
gests radical  measures  during  pregnancy.  The  x-rays  are  among  the 
most  recent  and  effective  means  of  treatment. 

Flat  Condylomata — modified  mucous  patches — are  of  syphilitic 
origin  and  may  involve  large  surfaces  of  the  vulva  and  vagina. 
They  are  soft,  grayish,  have  a  broad  base,  and  should  be  treated  by 
disinfectant  and  antisyphilitic  remedies. 

CARCINOMA  OF  THE  VULVA. 

Carcinoma  is  of  epiblastic  origin,  and  is  apt  to  be  of  the  pavement- 
cell  variety — epithelioma.  The  author  observed  one  case  of  adeno- 
carcinoma a  few  weeks  after  the  removal  of  a  cancerous  uterus.  In 
this  case  the  disease  doubtless  was  transplanted  from  an  adenocarci- 
noma of  the  uterus  to  the  vagina  during  the  operation  of  hysterectomy. 
Prompt  excision  of  the  vulvar  growth  was  followed  by  permanent  cure. 

Pavement- cell  Carcinoma  begins  as  a  small,  hard,  whitish,  rough 
and  painless  wart-like  excrescence,  situated  at  any  point  on  the  vulva, 
but  more  commonly  on  the  sulcus  between  the  labia  majora  and 
minora.  There  is  first  a  gradual  involvement  of  the  superficial 
structures  around  the  growth,  then  rapid  ulceration  and  pain.  The 
inguinal  glands  on  the  side  corresponding  to  the  disease  are  involved. 
The  margin  of  the  ulcer  is  elevated,  hard,  and  of  bluish-red  color. 
The  base  is  granular  and  covered  by  a  semi-opaque,  putrid  secretion. 

Small,  pearly  bodies  may  often  be  squeezed  from  the  epithelial 
nests  at  the  base ;  these  nests  are  highly  diagnostic.  The  labium 
becomes  greatly  infiltrated,  very  hard  and  thickened,  and  finally  is 
destroyed  by  ulceration.  The  discharge  has  a  most  offensive  odor. 
The  disease  rarely  extends  to  the  opposite  labium,  vagina,  or  abdom- 
inal wall.  It  may  invade  the  perineal  and  peri-anal  regions.  The 
disease  is  analogous  to  epithelioma  of  the  lip  and  of  other  parts  where 
skin  and  mucous  membrane  meet. 

The  Diagnosis  is  chiefly  from  lupus  and  syphilis.  Unlike  cancer, 
lupus  is  recognized  by  the  mildness  of  the  pain,  by  the  relative 
freedom  from  foul  secretions,  by  the  tendency  of  the  ulcers  to  cicatrize, 
by  the  slight  liability  of  extension  to  the  inguinal  glands,  and  by  the 
slow  progress  of  the  disease.  Epithelioma  destroys  life  in  about  two 
years  after  the  beginning  of  ulceration.  Syphilis  may  be  diiferentiated 
by  the  history  of  infection,  by  the  presence  of  secondary  and  tertiary 
lesions  elsewhere,  and  by  the  effect  of  specific  treatment. 

Cylindrical  Cell  Carcinoma — Adenocarcinoma. — The  swelling 
begins  more  deeply  in  the  cellular  tissue,  and  is  characterized  by  irreg- 


362  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

ular-shaped  cylindrical  cells  imbedded  in  the  meshes^  of  connective- 
tissue  fibres  and  by  more  rapid  progress  than  that  of  epithelioma.  The 
tumor  more  rapidly  breaks  down,  the  hemorrhage  is  frequent  and  pro- 
fuse, the  ichorous  discharge  is  abundant,  the  inguinal  glands  are  enlarged 
early,  and  systemic  effects  appear  earlier  and  are  more  marked.  The 
disease  terminates  in  sepsis  and  mardsmus.  Death  occurs  earlier  than 
in  epithelioma. 

Figure  160. 


Carcinoma  of  ihe  vulva. 

The  Treatment  is  radical  excision  if  possible  before  glandular  in- 
volvement. 

SARCOMA  OF  THE  VULVA. 

Sarcoma  is  of  mesoblastic  origin  and  is  so  rare  in  the  vtdva  as  to 
preclude  accurate  description.  The  possible  varieties  are  :  first,  round 
cell ;  second,  spindle  cell ;  third,  myxosarcoma ;  fourth,  melanosar- 
coma.  They  preferably  develop  in  the  labia  majora,  but  have  been 
found  in  the  nymphse.  The  growth,  according  to  the  variety,  may  be 
slow,  resembling  that  of  lipoma;^  or  ulceration  may  be  early,  rapid, 
and  destructive.^     The  usual  characteristics  of  sarcoma  of  the  vulva 

« Henkel.  "  Hildebrandt. 


TUMORS   OF  THE   VULVA   AND    VAGINA.  363 

are  rapid  growth,  late  ulceration,  variable  hemorrhages,  and  late  in- 
volvement of  the  inguinal  glands.  The  systemic  breakdown,  though 
more  rapid  and  marked,  resembles  that  of  carcinoma.  All  recorded 
cases  have  terminated  fatally.  Death  usually  results  from  rapid 
involvement  of  distant  organs  through  the  venous  current. 

The  Treatment  is  removal  at  the  earliest  possible  date.  The  author 
here  records  a  successful  operation  done  more  than  fifteen  years  ago 
for  the  removal  of  a  spindle-cell  sarcoma  of  the  mons  veneris.  There 
has  been  no  recurrence. 

CYSTS   OF  THE  VULVA. 

The  pathology  of  cysts  of  the  vulvovaginal  gland  has  been  ex- 
plained in  Chapter  XL,  under  Inflammation  of  Bartholin's  Glands. 
The  only  satisfactory  treatment  of  such  a  cyst  is  to  open  the  sac,  dis- 
sect out  the  sac-wall,  and  close  the  wound  with  sutures.  Sebaceous 
cysts  rarely  occur. 

FIBROMYOMA  OF  THE  VULVA. 

Fibromyoma  belongs  to  the  connective-tissue  group  of  benign 
tumors,  and  is  therefore  of  raesoblastic  origin.  It  is  composed  of 
fibrous  connective  tissue  and  a  variable  amount  of  muscular  fibres. 
The  histological  characters  of  this  tumor  will  be  given  more  fully 
under  the  subject  of  Fibromyoma  of  the  Uterus.  The  tumor  is  com- 
monly small,  and  when  large  is  apt  to  be  pedunculated;  it  is  smooth, 
irregular  in  shape,  is  not  adherent  to  the  skin,  and  according  to  the 
amount  of  fluid  in  the  interspaces  may  be  hard  or  soft ;  it  often  is 
ulcerated  from  friction,  but  is  rarely  the  seat  of  an  abscess.  The 
symptoms  are  mechanical,  and  are  due  to  weight  and  pressure. 

The  Treatment  is  incision. 

LIPOMA— FATTY  TUMOR  OF  THE  VULVA. 

Lipoma  is  composed  of  lobuli  of  adipose  tissue  in  a  fibrous  mesh- 
work,  and  originates  in  the  fatty  tissue  of  the  labia  majora  and  mons 
veneris.  It  is  distinguished  from  fibromyoma  by  the  greater  rapidity 
of  growth,  by  the  lobulated  surface,  and  by  a  peculiar  sensation  to  the 
touch.  This  sensation  is  such  as  would  be  expected  from  a  wad  of 
cotton  under  the  skin.  Lipoma  may  grow  to  the  weight  of  ten 
pounds,  may  extend  to  the  knees,  and  may  be  pedunculated ;  it  has 
been  mistaken  for  hernia. 

The  Treatment  is  excision. 

TUBERCULOSIS— LUPUS. 

Lupus,  from  the  pathological  point  of  view,  should  be  classed  as 
tubercular  inflammation.  The  tumor-like  mass,  however,  presents 
physical  characteristics  in  common  with  certain  tumors,  and,  therefore, 
is  introduced  here  from  the  clinical  and  diagnostic  points  of  view.  See 
Tubercular  Vulvitis,  Chapter  XL 


364  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

ENCHONDROMA  AND  NEUROMA  OF  THE  VULVA. 

Enchondroma  and  neuroma  are  surgical  curiosities.  Simpson  V  has 
reported  the  only  authentic  case  of  neuroma.  Schneevogt  and  Bar- 
tholin have  each  recorded  a  case  of  enchondroma. 


CYSTS  OF  THE  VAGINA. 

Vaginal  cysts,  though  not  common,  are  the  most  frequent  of  the 
tumors  originating  in  the  vagina  ;   they  are   probably  from  :  1,  the 

Figure  161. 


Vaginal  cj-sts. 

embryonal  remains  of  Gaertner's  (Wolffian)  ducts ;  or,  2,  from 
diverticula  of  Mueller's  ducts.  An  echinococcus  cyst^  has  been 
reported.  Embryonal  vaginal  cysts  are  usually  not  larger  than  a 
walnut,  although  Veit  has  reported  one  as  large  as  a  foetal  head.^ 
They  are  circumscribed,  tense,  elastic,  rarely  pedunculated,  and  com- 
monly unilocular  ;  they  occur  singly,  or  in  rare  instances  are  arranged 


1  Sutton.    Tumors,  Innocent  and  Malignant. 

2  Porak.  Arch,  de  Tocologie,  1884,  p.  163.    Pozzi. 

3  Pozzi.    Medical  and  Surgical  Gynecology. 


Medical  and  Surgical  Gynecology. 


TUMORS  OF  THE  VULVA   AND    VAGINA.  365 

in  groups  of  two,  three,  or  four  in  a  row.  The  cyst- wall  is  composed 
of  fibrous  tissue,  with  an  inner  lining  of  cylindrical  or  pavement 
epithelium  and  an  outer  covering  of  vaginal  mucous  membrane.  The 
contents  are  commonly  viscid,  transparent,  and  of  a  pale-yellow  color. 
The  occasional  chocolate  color  is  explained  by  the  presence  of  blood, 
pus,  and  epithelial  cells. 

The  differential  diagnosis .  is  from  cystocele,  rectocele,  emphysem- 
atous vaginitis,  and  vaginal  hernia.  Cystocele  is  demonstrated  or 
excluded  by  the  sound  in  the  bladder  and  the  finger  in  the  vagina ; 
rectocele  by  one  finger  in  the  rectum  and  another  in  the  vagina.  The 
cysts  of  emphysematous  vaginitis  contain  gas,  are  usually  multiple, 
and  do  not  follow  the  course  of  Gaertner's  ducts.  The  hernial  tumor 
temporarily  disappears  on  pressure  and  gives  an  impulse  on  coughing. 

Treatment. — If  the  cyst  is  within  easy  reach,  the  treatment  is  exci- 
sion ;  if  it  is  very  close  to  the  rectum,  bladder,  or  ureters,  the  vaginal 
side  should  be  removed,  the  remainder  curetted  or  cauterized,  and  the 
wound  packed  with  gauze. 

FIBROMYOMATA  OF  THE  VAGINA. 

Fibromyomata  of  the  vagina  differ  in  no  essential  point  from  similar 
growths  of  the  vulva  and  uterus.  They  are  of  rare  occurrence,  and 
usually  small,  but  sometimes  are  large  enough  to  give  the  mechanical 
symptoms  of  pressure  and  weight. 

The  Treatment  is  enucleation. 

CARCINOMA  AND  SARCOMA  OF  THE  VAGINA. 

Carcinoma  of  the  vagina  usually  occurs  by  extension  from  primary 
carcinoma  of  the  cervix,  uterus,  or  rectum ;  it  rarely  originates  in  the 
vagina.     Sarcoma  of  the  vagina  is  almost  unknown. 

The  Treatment — early  excision — gives  most  unsatisfactory  results. 

23 


CHAPTEE  XXVI. 

TUMORS  OF  THE  UTERUS— MYOMA 

ETIOLOGY,  HISTOLOGY  AND  HISTOGENENIS,  NOMENCLATURE, 
CLASSIFICATION,  SYMPTOMS,  DIAGNOSIS,  DIFFERENTIAL 
DIAGNOSIS,  PROGNOSIS. 

The  uterine  myoma  is  the  most  common  uterine  tumor,  and  like 
the  uterus  is  composed  chiefly  of  fibrous  connective  tissue  and  non- 
striated  musular  fibres. 

Etiolog-y  of  Myoma. 

Myomata  commonly  develop  during  the  period  of  sexual  maturity, 
rarely  if  ever  before  puberty  or  after  the  menopause.  The  common 
impression  that  they  are  more  common  in  the  negro  than  in  the  white 
race  appears  to  be  disproved  by  the  investigations  of  Howard  Kelly 
and  Daniel  Williams.^  Heredity  probably  is  an  etiological  factor.  In 
the  older  literature  they  are  said  to  result  from  traumatism,  Init  the 
assertion  is  purely  speculative,  no  evidence  having  been  brought  for- 
ward in  support  of  it.     The  causes  of  these  tumors  are  not  known. 

Pathological  Anatomy  of  Myoma. 

In  most  cases  the  tumor  is  circumscribed  sharply,  single  or  multi- 
ple, hard  or  soft,  of  pinkish  or  whitish  color  commonly  of  slow  growth, 
and  varying  in  size  within  wide  limits.  On  cross-section  the  gross 
appearance  is  glistening  and  may  be  homogeneous,  but  more  usually 
is  striated  with  dense  fibrous  septa  which  divide  the  section  into  lobules. 
The  spaces  between  the  septa  are  filled  with  muscle-fibres.  See  Figures 
156  and  157.  In  later  development  a  loose  fibrous  capsule  is  formed 
which  sharply  defines  the  growth  from  its  surroundings ;  and  from 
which  the  growth  may  be  shelled  out  readily;  the  blood-vessels  of  the 
fibrous  capsule  penetrate  through  the  septa  to  the  muscle-cells. 

These  growths  are  subject  occasionally  to  extensive  venous  obstruction 
and  dilatation  which  often  leads  to  the  formation  of  cavernous  spaces  ; 
hence  the  blood-supply,  not  only  in  different  tumors,  but  at  different 
times  in  the  same  tumor,  is  subject  to  great  variation.  This  change- 
able blood-supply  accounts  for  corresponding  variation  from  time  to 
time  in  the  size  of  a  tumor.  Hard  white  tumors  of  a  slow  growth, 
containing  a  relatively  large  amount  of  fibrous  tissue,  are  apt  to  have  a 
limited  blood-supply.  On  the  other  hand,  the  soft  pinkish  tumor  of 
more  rapid  growth,  w^ith  a  relative  preponderance  of  muscle-cells,  is 
always  more  vascular. 

1  Chicago  Medical  Recorder. 


PLATE  XIV 


S;.- 


'V"'-!S^2S$-^ 


ooSs" 


'\  'm( 


Microscopic  Section,  of  a  Uterine  Myoma. 

The  upper  part  of  this  figure  contains  few  muscle  cells  and  much,  fibrous 
stroma  (fibromyoma).  The  remainder  of  the  field  shows  an  abundance  of  muscle 
cells  and  relatively  speaking  a  small  amount  of  fibrous  stroma  (myofibruma) 
In  the  lower  half  of  the  picture  the  spindle  cells  are  arranged  in  whirls.  Just 
above  these  whirls  is  a  densely  packed  mass  of  spindle  cells  the  nuclei  of  which 
are  cut  longitudinally,  and  just  above  this  mass  is  a  belt  of  cells  the  nuclei  of 
which  appear  circular  in  shape  because  they  are  cut  transversely.  From  a  histo- 
logical point  of  view  a  uterine  myoma  may  have  all  the  microscopic  appearance 
of  normal  uterine  tissue.  This  drawing  in  different  parts  illustrates  normal  uterus 
tissue,  fibromvoma,  and  mvofibroma.     loo  diameters 


TUMORS  OF  THE   UTERUS— MYOMA.  367 

Histology  and  Histogenesis  of  Myoma. 

The  characteristic  cell  elements  are  non-striated  fusiform  muscle- 
fibres  with  elongated  nuclei  which  may  be  combined  in  any  propor- 
tion with  fibrous  tissue.  Nothing  is  known  of  the  histogenesis  of 
these  tumors  beyond  the  fact  that  they  originate  in  the  myoblast,  a 
fact  which  stamps  them  as  myomata,  regardless  of  the  relative  quan- 
tity of  the  muscular  and  connective  tissue.  The  tumor  does  not  lose 
its  identity  as  a  myoma  even  though  all  the  muscular  elements  have 
disappeared  and  been  replaced  by  fibrous  tissue. 

Nomenclature  of  Myoma. 

Myofibroma,  Fibromyoma,  and  Fibroma. — A  soft  vascular 
tumor,  because  it  contains  a  large  amount  of  muscular  tissue,  has  been 
called  myofibroma  or  leiomyoma.  The  hard,  more  fibrous  myoma 
often  is  called  fibromyoma  or  fibroma.  There  is  no  definite  line 
between  the  so-called  myofibroma  and  fibromyoma.  The  terms  are 
relative  and,  to  an  extent,  arbitrary,  and  to  be  used  only  for  conven- 
ience of  description. 

Secondary  Changes  of  Myoma. 

The  secondary  changes  common  to  uterine  myoma  are  : 
Fatty  degeneration.  Calcification. 

Mucoid  degeneration.  Septic  infection. 

Cystic  degeneration.  Malignant  changes. 

Fatty  Degeneration. — This  secondary  change  pertains  to  the 
muscle-fibres  and  may  destroy  them  completely,  leaving  behind  a 
contracting  formation  of  fibrous  connective  tissue  which  in  the  process 
of  solidification  is  apt  to  crush  out  and  destroy  the  blood-supply  so 
that  the  tumor  deprived  of  nutrition  becomes  a  hard  rudimentary 
mass ;  the  process  which  may  pertain  to  the  whole  tumor  or  to  parts 
of  it  is  a  frequent  factor  in  the  atrophic  change  of  the  menopause  and, 
especially  in  small  tumors,  explains  numerous  spontaneous  cures 
occurring  at  this  period. 

Mucoid  Degeneration. — This  process,  usually  preceded  by  oedema 
and  rapid  increase  in  the  size  of  the  tumor,  occurs  principally  in  large 
fibromyomata,  and  is  characterized  by  the  conversion  of  the  fibrous 
tissue  into  mucous  substance  resembling  the  vitreous  humor  of  the  eye. 
The  structures  which  form  the  boundary  of  the  softened  spaces  may 
show  every  gradation  from  typical  spindle  cells  to  myxomatous  cells 
of  the  spider-like  shape.  There  may  be  developed  numerous  small 
cysts  in  a  tumor  or  a  single  large  spurious  fibrocyst  having  for  its  wall 
the  fibrous  capsule  of  the  orignal  tumor.  This  is  called  a  fibrocystic 
tumor.     Figure  162. 

Cystic  Degeneration  may  occur  as  follows  :  CEdema  may  cause 
so  much  dilatation  of  the  lymph-spaces  as  to  give  the  whole  tumor 
an  appearance  of  marked  cystic  degeneration,  or  the  dilated  cavernous 
veins  already  described  may  be  converted  into  blood-cysts. 

Calcification  occurs  most  frequently  in  atrophied  subperitoneal 


368 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


tumors,  and  may  pertain  to  the  individual  fibrous  septa  or  to  the 
capsule  or  in  exceptional  cases  the  entire  tumor  may  be  displaced 
by  lime  salts  and  converted  into  a  stone — so-called  womb-stone.  A 
section  of  such  a  stone  made  by  the  saw  will  sometimes  take  a  high 
polish  with  the  whole  arrangement  of  the  fibrous  septa  and  capsule 
reproduced  in  the  lime  salts.  More  commonly  the  spaces  between 
the  septa  do  not  calcify,  but  disappear  by  some  other  degenerative 
process  giving  the  calcified  part  a  porous,  worm-eaten,  or  coral-like 
appearance.     When  the    calcification    is    chiefly   or   wholly    in  the 

Figure  162. 


Fibrocystic  myoma  uteri.    The  interior  of  the  tumor  shows  the  fibrocystic  changes. 


fibrous  capsule  the  tumor  is  covered  by  a  thin  hard  crust  which 
may  resemble  closely  the  foetal  skull.  In  the  enucleation  of  such 
a  tumor  from  the  corpus  uteri  the  writer  once  found  a  calcified 
capsule  which  under  the  thin  wall  of  the  corpus  uteri  felt  so  much  like 
a  foetal  head — including  the  sutures  and  fontanelles — that  he  was  led 
almost  to  abandon  the  operation. 

Septic  Infection. — A  myoma  Avhich  has  for  years  given  rise  to  no 
inconvenience,  may  become  suddenly  infected,  with  rapid  increase  in 
size,  high  pulse  and  temperature,  great  pain,  and  evidences  of  sep- 
ticaemia. The  cause  of  infection,  sometimes  obscure,  is  explained 
usually  by  the  presence  of  one  or  more  of  the  known  causes  of 
pelvic  inflammation,  such  as  electrolysis,  the  unclean  intra-uterine 
sound,  external  violence,  septic  operations,  and  extension  of  infection 


TUMORS  OF  THE  VTERUS-MYOMA. 


369 


from  an  adherent  intestine  or  bladder.     A  fatal  result  is  almost  inevi- 
table unless  the  diagnosis  is  made  early  and  the  tumor  removed. 

Malignant  Changes  will  be  considered   in  Chapters  XXVIIIc 
and  XXIX.,  on  Carcinoma  and  Sarcoma. 


Classification  of  Myoma. 

Location. — The  tumor  may  be  anywhere  in  the  uterine  substance. 
Figure  163  ;  but  in  the  majority  of  cases  it  is  in  the  body  of  the 

Figure  163. 


Intramural,  submucous,  and  subperitoneal  myomata.  A  pedunculated  subperitoneal  myoma 
sometimes  is  called  wrongly  extra-uterine  myoma.  A  pedunculated  submucous  myoma  is 
called  intra-uterine  polypus. 

uterus.     Tumors  of  the  cervix  uteri  are  apt  to  be  small,  those  of  the 
corpus  larger. 

The  regional  classification,  Figure  163,  is  : 

1.  Intramural  (interstitial)  myomata. 

2.  Submucous  myomata. 

3.  Subperitoneal  myomata. 

4.  Cervical  myomata. 

1.  Intramural  Myomata. — All  myomata  are  primarily  intramural — 


370 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


i.  e.,  thev  originate  in  the  musculature,  but  the  term  intramural  is 
reserved  here  for  tumors  surrounded  wholly  by  the  muscular  wall  of 
the  uterus.  The  growth  in  most  cases  is  firm,  sharply  defined^  and 
encapsulated  or  in  exceptional  cases  soft,  ill-defined,  and  without  a 
definite  capsule  ;  it  has  from  its  situation  an  abundant  blood-supply  on 
all  sides,  and  for  this  reason  may  grow  rapidly  to  large  size.  It  will 
always  irritate  the  surrounding  muscular  tissues,  and  cause  them  to 
contract  upon  it  so  that  if  it  is  nearer  to  the  endometrium  than  to  the 


Figure  164. 


Intramural  mj-omata.    The  lower  tumor  exerts  pressure  on  all  the  pelvic  organs.    The  upper 
tumor  displaces  the  uterus  upward  by  traction. 

peritoneum,  the  preponderance  of  muscular  tissue  on  the  peritoneal 
side  will  force  it  slowly  toward  the  interior  of  the  uterus  and  tend 
to  make  of  it  a  submucous  tumor.  If  the  preponderance  of  mus- 
cular tissue  is  between  the  tumor  and  the  endometrium,  the  direc- 
tion of  least  resistance  will  be  toward  the  peritoneum,  and  the  growth 
will  tend  to  become  subperitoneal.  The  same  uterus  may  contain  one 
or  many  intramural  tumors.  Figure  165.  Intramural  is  synonymous 
with  interstitial.    Figure  164. 

2.  Submucous  Myomata    may   originate  in  the  muscular  tissue  of 


TUMORS  OF  THE   UTERUS— MYOMA. 


!71 


the  submucosa,  and  be,  therefore,  primarily  submucous ;  or  an  intra- 
mural tumor,  as  explained  in  the  preceding  paragraph,  may  become 
secondarily  submucous.  The  secondarily  submucous  tumor  is  apt  to 
remain  sessile — i.  e.,  to  have  little  tendency  to  form  a  pedicle.  The 
primarily  submucous  tumor,  on  the  contrary,  develops  a  pedicle. 
The  pedunculated  submucous  myoma  is  vascular,  soft,  commonly 
single,  usually  corporeal,  rarely  cervical,  in  most  cases  small  but 
may  be  large  enough  to  distend  the  uterus  enormously.     It  may  be 

Figure  165. 


Multiple  myomata,  suitable  for  vagiual  hysterectomy. 

forced  by  uterine  contractions  through  the  cervix  uteri,  and  the 
pedicle  by  the  downward  traction  of  the  tumor  may  become  much 
elongated  so  that  the  extruding  mass  may  finally  be  forced  through 
the  vulva.  The  pedicle  may  be  constricted  by  pressure  of  the  cer- 
vical canal  or  may  become  twisted  with  consequent  gangrene  of  the 
tumor  and  spontaneous  detachment  and  cure,  but  not  uncommonly 
the  extruded  mass  remains  oedematous  and  hemorrhagic,  a  menace 
to  health  or  a  destroyer  of  life. 


372 


TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS. 


Adhesions  may  form  between  an  intra-uterine  tumor  and  the  endo- 
metrium or  cervical  mucosa,  and  by  partial  or  complete  obliteration 
of  the  uterine  cavity  lock  the  secretions  within  the  uterus. 

3.  Subperitoneal  Myomata — sometimes  called  subserous — may  be 
either  single  or  multiple,  and  occasionally  may  reach  the  enormous 
size  of  forty  or  fifty  pounds.  These  tumors,  primarily  intramural, 
have  been  forced  outward  by  uterine  contractions  until  they  become 
secondarily  subserous,  or  such  a  tumor  has  worked  its  way  from  the 
point  of  origin  into  the  territory  between  the  folds  of  the  broad  liga- 
ment, and  become  an  intraligamentous  myoma,  A  pedunculated  sub- 
serous tumor  may,  in  rare  cases,  become  detached  from  the  uterus  and 

Figure  166. 


Submucous  pedunculated  myoma,  resembling  an  inverted  uterus. 


remain  as  a  migrating  tumor,  free  and  harmless  in  the  abdominal 
cavity ;  or  may  receive  its  nutrition  through  new  adhesions  which 
have  formed  between  it  and  some  of  the  pelvic  or  abdominal  viscera ; 
or  may  become  gangrenous  and  give  rise  to  serious  infection  ;  or  may 
atrophy  and  disappear. 

4.  Cervical  Myomata. — Myomata  of  the  cervix  uteri  are  of  rather 
infrequent  occurrence,  follow  the  same  law  as  to  development  and 
location  as  myomata  of  the  body  of  the  uterus,  and  usually  spring 
from  the  supravaginal,  rarely  from  the  infravaginal,  portion  of  the 
cervix.  A  submucous  cervical  myoma  is  usually  pedunculated,  and 
may  have  the  appearance  of  a  uteru^  inverted  into  the  vagina.     An 


TUMORS  OF  THE   UTERUS— MYOMA.  373 

intramural  cervical  mycoma  causes  thickening  of  the  cervical  wall 
around  it,  and  by  pressure  and  stretching  a  corresponding  thinning  of 
the  opposite  wall. 

Symptoms  of  Myoma. 

The  symptoms  may  be  described  under  the  following  heads : 
Hemorrhage.     Congestion.  Pain  and  discomfort. 

Pressure  and  traction.  Miscellaneous  symptoms. 

Hemorrhage,  the  most  important  and  the  most  pronounced  symp- 
tom, begins  not  as  a  sudden,  profuse  flow,  as  in  carcinoma,  but  as  a 
gradual  increase  in  menstruation ;  the  bleeding  occurs  frequently,  is 
prolonged,  and  may  result  from  ordinary  conditions,  such  as  exer- 
cise or  coitus.  The  irritating  presence  of  the  tumor  predisposes  to 
hemorrhagic  endometritis,  the  hemorrhagic  area  being  the  endome- 
trium, not  usually,  as  sometimes  supposed,  the  tumor  itself.  Fatal 
hemorrhage,  however,  has  occurred  from  rupture  of  a  blood-vessel  in 
the  growth.^ 

The  degree  of  hemorrhage  depends  upon  the  location  of  the  tumor 
relative  to  the  endometrium  and  the  peritoneum.  The  closer  to  the 
uterine  mucosa,  the  greater  the  hemorrhage ;  the  nearer  to  the  peri- 
toneum, the  less  the  hemorrhage  ;  hence  menorrhagia  is  almost  invari- 
able with  the  submucous  variety,  less  severe  but  very  common  with  the 
intramural,  and  usually  slight  or  absent  with  the  subperitoneal.  The 
pedunculated  submucous  and  the  pedunculated  subperitoneal  myomata 
stand  at  the  two  extremes,  the  former  producing  the  greatest  hemor- 
rhage, the  latter  little  or  none  at  all.  Hemorrhage  is  not  always 
proportionate  to  the  size  of  the  tumor ;  a  large  tumor  may  obstruct 
the  flow  of  blood,  or  by  pressure-atrophy  of  the  endometrium  may 
give  rise  to  scanty  menstruation  ;  on  the  other  hand,  a  small  submucous 
myoma  may  cause  alarming  uterine  hemorrhage. 

A  myoma  often  delays,  prolongs,  or  prevents  the  menopause ;  it 
may  participate  in  the  atrophic  processes  of  this  crisis,  and  become 
smaller,  or  disappear ;  in  some  cases  the  menopause  has  the  opposite 
effect — i.  e.,  great  and  sudden  increase  of  growth.  Such  increase  is  a 
strong  indication  for  myomectomy  or  hysterectomy. 

Pressure  and  Traction  cause  numerous  mechanical  and  other  dis- 
turbances of  the  rectum,  bladder,  ureters,  urethra,  and  of  the  uterus 
itself,  such  as  hemorrhoids,  constipation,  rectal  and  vesical  tenesmus, 
mucous  diarrhoea,  frequent  urination,  dysuria,  retention  of  urine,  and 
uterine  displacements.  Pressure  upon  the  venous  trunks  often  causes 
great  dilatation  of  the  veins  and  passive  congestion  throughout  the 
pelvis.  Pressure  on  a  ureter  has  given  rise  to  obstruction  and  caused 
hydronephrosis. 

A  myoma  in  the  anterior  uterine  wall,  even  though  small,  may,  by 
pressure,  set  up  extreme  vesical  irritation  with  the  possible  conse- 
quence of  cystitis.  Pressure  from  a  myoma  incarcerated  under  the 
promontory  of  the  sacrum  unless  the  tumor  spontaneously  or  nor- 
mally is  forced   up  into  the  abdominal  cavity,  will  cause  great  pain 

» Duncan.    Edinburgh  Medical  Journal.  1867.    Pozzi. 


a74  TUMORS,    TUBAL  PREGNANCY,  MALFORMATIONS. 

and  interference  with  functions  not  only  in  the  pelvis,  but  also  in  the 
lower  extremities. 

Uterine  displacements  may  result  from  pressure,  traction,  and 
increased  weight.  A  tumor  situated  above,  below,  to  either  side,  in 
front,  or  back  of  the  uterus  may  force  it  by  pressure  in  the  opposite 
direction,  or  may  draw  it  by  traction  in  the  same  direction,  or,  by 
increasing  the  weight  of  the  uterus,  may  cause  prolapse.  A  myoma, 
for  example,  which  has  grown  too  large  for  the  pelvis  to  hold  it,  and 
has  therefore  risen  above  the  pelvic  brim  into  the  abdomen,  will  cause 
upward  displacement  by  traction. 

The  Pain  and  Discomfort  incident  to  this  affection  have  been 
mentioned  in  the  foregoing  paragraphs  under  Pressure  and  Traction. 
Backache,  bearing-down,  dragging  sensations  in  the  pelvis,  dysmenor- 
rhoea,  and  painful  uterine  contractions  are  familiar  subjective 
symptoms.  Expulsive  contractions  of  the  uterus  upon  a  mural  or 
submucous  myoma,  especially  during  the  period  of  menstrual  conges- 
tion and  irritation,  may  be   transient  or  constant,  moderate  or  severe. 

Miscellaneous  Symptoms.  —  Intermenstrual  uterine  discharges 
caused  by  the  great  vascularity  of  the  uterine  mucosa  and  the  hyper- 
trophic condition  of  the  glands,  usually  occur  in  the  progress  of  the 
disease  ;  they  may  be  purulent  or  serous,  or  both  ;  are  mixed  com- 
monly with  blood,  and  are  often  profuse  and  exhausting.  The  watery 
discharge — hydrorrhoea — usually  associated  with  malignant  disease  is 
very  infrequent  in  myoma,  but  when  present  is  more  transient  and 
less  offensive  than  in  cancer  or  sarcoma. 


Diagnosis  of  Myoma. 

Uterine  myomata,  unless  very  small  and  associated  with  metritis, 
usually  are  not  difficult  to  recognize.  The  symptoms  outlined  in  the 
foregoing  paragraphs,  although  diagnostic,  are  far  from  pathognomonic. 
The  diagnosis  will  depend  always  upon  the  physical  signs— that  is, 
upon  inspection,  palpation,  conjoined  examination,  and  exploration  of 
the  uterine  cavity.     See  Figures  16  and  17,  Chapter  III. 

Inspection  and  Palpation  will  show  enlargement  of  the  abdomen 
unless  the  tumor  is  too  small  to  produce  that  result.  External  palpa- 
tion, if  the  tumor  is  large,  discloses  in  the  pelvis  and  lower  abdomen  a 
solid,  usually  hard,  though  sometimes  soft  mass.  Exceptionally  the 
growth  has  a  peculiar  elasticity  which  resembles  fluctuation,  but  lacks 
the  percussion-wave  peculiar  to  cystic  tumors.  The  tumor  may  be 
single  and  symmetrical,  globular  or  oblong.  The  presence  of  multiple 
myomata  may,  with  their  numerous  projections,  give  to  the  uterus  a 
most  irregular  form.  Many  small  tumors  may  be  distributed  so 
evenly  throughout  the  uterine  walls  as  to  cause  a  nearly  symmetrical 
enlargement  of  the  uterus,  but  in  such  a  case  the  surface  usually  gives 
to  the  touch  a  sensation  of  small  nodular  irregularities.  Inspection, 
palpation,  and  percussion  will  be  considered  further  in  connection  with 
differential  diagnosis. 

Conjoined  Examination. — The  index  or  the  index  and  middle 
fingers  in  the  vagina,  the  palmar  surface  directed  toward  the   uterus 


TUMORS  OF  THE   UTERUS— MYOMA.  375 

and  tumor,  and  the  palpating  fingers  of  the  right  liand  over  the 
abdomen,  if  the  abdominal  muscles  are  not  too  tense,  will  enable  the 
examiner  to  outline  the  uterus  and  its  myomatous  projections.  In  the 
majority  of  cases  ordinary  conjoined  examination  will  complete  the 
diagnosis.  The  palpation  often  is  facilitated  by  means  of  the  thumb 
in  the  vagina  and  the  index-finger  in  the  rectum.  This  enables  the 
operator  to  pick  up,  so  to  speak,  the  enlarged  uterus  between  the 
thumb  and  finger.  Information  through  the  examining  finger  is 
obtained  not  so  much  by  forcing  it  up  against  the  tumor  as  l)y  strong 
pressure  of  the  tumor  against  it  by  means  of  the  right  hand  over  the 
abdomen.  If  the  abdominal  walls  are  rigid  or  thick,  anaesthesia  may 
be  necessary. 

Conjoined  Intra-uterine  Examination  wnth  an  index-finger  in  the 
uterus  and  a  hand  over  the  abdomen  is  possible  only  when  the 
uterine  canal  is  dilated,  a  condition  which  may  be  brought  about  by 
instrumental  means  or  by  uterine  contractions  upon  an  intra-uterine 
tumor.  The  index-finger  in  the  dilated  uterus  will  recognize  by  direct 
touch  the  presence  and  character  of  an  intra-uterine  growth. 
Exploration  by  the  Sound. — The  sound  will  show : 

The  direction  of  the  uterine  canal. 

The  length  of  the  uterine  canal. 

The  shape  of  the  uterine  cavity. 

The  relations  of  tumors  to  the  uterine  cavity. 
TJie  one  fact  constant  for  all  uterine  myoma.ta  is  elongation  of  the 
uterine  cavity,  and  the  presence  or  absence  of  elongation  can  be  ascer- 
tained by  the  sound  or  probe.  The  increased  length  is  proportionate 
to  the  size  of  the  tumor,  and  may  reach  seven  or  more  inches.  Unless 
care  is  used,  a  submucous  tumor  may  obstruct  the  passage  of  the 
sound  and  lead  to  wrong  measurement.  Submucous  and  intramural 
tumors  project  into  the  uterine  cavity,  and  thereby  render  the  uterine 
canal  tortuous,  and  unless  the  myoma  is  too  soft  and  small  to  be 
recognized  the  sound  or  probe  will  be  deflected,  and  as  it  glides  over 
the  growth  the  deflection  will  indicate  the  size  of  the  growth  and  the 
degree  to  which  it  projects  into  the  uterine  cavity. 

Differential  Diagnosis. 

The  principal  lesions  from  which  myoma  must  be  differentiated 
are  the  following : 

Intra-uterine  pregnancy.  Incomplete  abortion. 

Tubal  pregnancy.  Ovary. 

Carcinoma  and  sarcoma.  Pelvic  infiltrations. 

Chronic  metritis.  Pelvic  cysts. 

Inversion  of  the  uterus.  Sactosalpinx. 

Uterine  displacements.  Floating  kidney. 

Normal  Pregnancy. — Normal  utero-gestation  will  be  excluded 
by  the  absence  of  the  usual  signs  of  pregnancy.  The  difficulties  in 
diagnosis  will  arise  commonly  in  abnormal  pregnancies,  especially  in 
placenta  prsevia  and  in  pseudo-menstruation  connected  with  preg- 
nancy.    If  the  enlargement  of  the  uterus  be  symmetrical  and  the  rate 


376 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


of  growth  usual  for  a  pregnant  uterus,  and  the  os  be  soft  and  patulous; 
pregnancy  is  highly  probable.  If,  on  the  other  hand,  the  cervix  be 
hard,  the  os  uon-patulous,  and  the  uterus  irregular  in  outline  from  the 
presence  of  a  hard,  resisting  mass,  the  diagnosis  is  probably  myoma. 
Not  very  infrequently  myoma  and  pregnancy  coexist;  then  if  the 
tumor  is  large  and  the  foetus  small,  the  difficulty  of  diagnosis  is  great. 
In  doubtful  cases  the  myoma,  if  present,  will  declare  itself  by  rela- 
tively slow  growth.  The  following  tabular  statement  contains  the 
chief  points  of  difference  between  myoma  and  pregnancy  • 


Pregnancy. 

1.  History  of  pregnancy. 

2.  Uterus  soft  and  elastic. 

3.  Consistence  varies  with  uterine  contrac- 
tions. 

4.  Cervix  soft. 

5.  Regular  and  uniform  increase  in  size  of 
uterus. 

6.  Later,  ballottement,  foetal  heart-tones. 

7.  Palpation  of  fcetus. 


Myoma. 

1.  Absent. 

2.  Usually  irregular  in  form  and  harder. 

3.  Uterine    contractions    not   marked— very 
important  sign. 

4.  Hard  or  not  so  soft. 

5.  Growth  slower  and  irregular. 

6.  Absent. 

7.  Palpation  of  myoma. 


Tubal  Pregnancy  gives  a  history  of  gestation.  The  gestation-sac 
closely  resembles  sactosalpinx.  Rupture  of  the  tube  produces  pelvic 
hgematocele.  A  decidua  may  be  cast  out  of  the  uterus.  The  reader 
is  referred  to  the  clinical  forms  of  endometritis.  Chapter  XVII. 

If  the  tubal  pregnancy  has  resulted  in  pelvic  hsematocele  by  tubal 
rupture  or  tubal  abortion,  the  differential  points  will  be  as  follows : 


Hematocele. 

1.  History  of  tubal  pregnancy. 

2.  Sudden  appearance,  shock,  severe  pain, 
and  evidence  of  hemorrhage. 

3.  Consistence   of  mass   usually   soft,  later 
may  be  hard. 

4.  Not  sharply  outlined. 

5.  Later,  mass  shrinks  and  becomes  harder 
or  may  suppurate. 


Myoma. 

1.  Absent. 

2.  Absent. 

3.  Usually  hard. 

4.  Sharply  outlined. 

5.  Commonly  increases  in  size ;  may  decrease 
after  menopause. 


Diagnosis  of  Myoma  complicating  Pregnancy. — ISIyoma  may  be  mis- 
taken for  the  foetal  head,  elbow,  or  knee.  Intramural  myoma  compli- 
cated by  pregnancy  takes  on  rapid  increase  of  growth,  is  softer  than 
formerly,  but  firmer  than  the  pregnant  uterus ;  this  variability  in  con- 
sistence is  almost  proof  of  complicating  pregnancy,  and  calls  for  re- 
peated examinations.  Later,  one  may  palpate  the  fcetus,  elicit  ballotte= 
ment,  and  hear  the  foetal  beat. 

Carcinoma  and  Sarcoma. — The  evidences  of  malignant  disease, 
including  the  sudden  onset  of  hydrorrhoea,  the  bloody,  fetid  discharge, 
the  rapid  emaciation,  and  the  microscopical  finding  of  carcinoma  or 
sarcoma  in  the  scrapings,  will  exclude  myoma  definitely.  A  slough- 
ing, extruding  myoma  may,  however,  both  in  the  profuse  fetid  dis- 
charge and  in  the  sensation  to  the  examiner  on  touch,  closely  resemble 
carcinoma  or  sarcoma  of  the  cervix.  The  diagnosis  then  will  depend 
on  the  microscope. 


TUMORS  OF  THE   UTERUS— MYOMA. 


377 


Metritis  often  complicates  uterine  myomata,  and  is  difficult,  often 
impossible,  to  differentiate  from  small,  multiple,  interstitial  growths. 
The  symmetrical  form  of  the  uterus  is  the  distinguishing  feature  of 
metritis.     See  differential  tabular  statement  below. 


Figure  167. 


Myomatous  uterus,  five  months  pregnant.    Infection  of  myoma,  and  consequent  peritonitis 
from  twisted  pedicle.    Hysterectomy.    (Case  referred  by  Dr.  A.  C.  Haven.) 


Chronic  metritis. 

1.  Uniform  enlargement. 

2.  Uniform  hardness. 

3.  Uterus  not  larger  than  two  or  three  times 
the  normal  size. 


Myoma. 

1.  Enlargement  usually  irregular. 

2.  Uterus  softer  than  tumor. 

3.  Size  may  increase  to  thirty  or  forty  pounds 


Inversion  of  the  Uterus. — A  uterine  myoma  protruding  into  the 
vagina  may  have  the  appearance  of  an  inverted  uterus.  The  sound 
then  will  glide  past  the  tumor  into  the  uterus  above.  Conjoined 
recto-abdominal  exmination  will  demonstrate  the  absence  of  the  uterus 
in  its  normal  location  if  it  be  inverted  into  the  vagina.  See  Inversion 
of  the  Uterus. 

Displacements  of  the  Uterus  are  recognized  on  conjoined  exami- 
nation by  the  symmetrical  contour  of  the  uterus  and  by  the  change  in 
the  direction  of  the  uterine  canal  as  demonstrated  by  the  sound. 

Incomplete  Abortion  with  hemorrhage  will  be  recognized  by  the 
history  of  interrupted  pregnancy  and  by  microscopical  examination  of 
the  scrapings. 


378 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


The  Ovary,  especially  if  adherent  to  the  uterus,  sometimes  simu- 
lates a  small  pedunculated  subserous  myoma.  The  myoma,  however, 
is  smoother,  more  firm,  and  less  sensitive  to  pressure. 

Pelvic  Inflammatory  Infiltrations,  unlike  myomata,  always  give 
a  history  of  pelvic  inflammation,  are  very  tender  on  pressure,  immo- 
bile, and  prone  to  disappear  by  resolution  or  to  undergo  suppuration. 
See  differential  diagnosis  of  Pelvic  Cellulitis,  Chapter  XX. 

Figure  168. 


Myoma  complicated  by  pregnancy.    Author's  case.    Complete  hysteromyomeclomy  at 
St.  Luke's  Hospital,  Chicago;  recovery. 

Pelvic  Cysts  are  distinguished  from  myomata  by  fluctuation,  by 
separability  from  the  uterus  on  palpation,  by  more  rapid  growth,  by 
the  normal  or  nearly  normal  length  of  the  uterine  cavity,  and  by  the 
absence  of  uterine  hemorrhage.     Figure  18. 

Sactosalpinx  develops  more  rapidly,  is  situated  commonly  at  the 
side  of  the  uterus,  is  of  elongated,  ovoid  form,  is  fluctuating,  is  more 
or  less  tender  on  pressure,  and  does  not  cause  material  enlargement 
of  the  uterine  cavity. 


TUMORS  OF  THE   UTERUS— MYOMA.  379 

Floating  Kidney,  unless  adherent,  is  replaced  readily,  has  the 
form  of  a  kidney,  and  may  be  tender  to  pressure.  See  Displacement 
of  the  Kidney,  Chapter  XXXIII. 

Prognosis  of  Myoma. 

Non-operative  Prognosis. — Myoma  may  be  present  throughout 
the  period  of  sexual  activity  and  produce  no  subjective  symptoms,  or 
it  may  give  rise  to  the  symptoms  already  outlined.  It  may  partici- 
pate in  senile  atrophy  of  the  reproductive  organs  at  the  menopause  or 
in  involution  after  pregnancy,  and  thus  become  much  smaller  or  dis- 
appear. On  the  other  hand,  at  either  of  these  times  it  may  grow 
larger.  It  usually  develops  rapidly  during  gestation.  Even  small 
growths,  if  near  the  endometrium,  may  threaten  life  from  hemor- 
rhage. Complicating  cardiac  and  renal  diseases  render  the  prognosis 
more  grave.  The  causes  of  death  include  hemorrhage,  sepsis,  perito- 
nitis, and  secondary  changes  in  the  tumor  itself. 

Natural  Cure. — There  are  three  natural  modes  of  cure : 

1.  Great  shrinkage  or  disappearance  by  absorption — rare;  reason 
unknown. 

2.  Detachment  of  intra-uterine  or  intramural  myoma  and  expulsion 
through  the  cervix  uteri  or  vagina  ;  detachment  of  subserous  peduncu- 
lated myoma  into  the  peritoneum.     See  Subperitoneal  Myomata. 

3.  Disintegration  and  gangrene. 

The  Operative  Prognosis  will  be  found  at  the  end  of  the  next 
chapter. 


CHAPTER  XXVII. 

TUMOKS  OF  THE  UTERUS  (Continued). 

TREATMENT   OF  MYOMA. 

The  treatment  includes  medication,  manipulations,  intra-uterine 
tamponade,  intra-uterine  styptics,  electrolysis,  and  surgical  operations. 
The  treatment  is,  therefore,  non-surgical  and  surgical. 

NON-SURGICAL  TREATMENT. 

1.  Medication. 

2.  Manipulations. 

3.  Intra-uterine  tamponade. 

4.  Intra-uterine  styptics. 

5.  Electrolysis. 

6.  Expectant  treatment. 

1.  Medication. 

Ergot  stands  at  the  head  of  the  numerous  drugs  that  have  been 
used  in  the  treatment  of  uterine  myoma.  Indeed,  no  other  drug, 
except  possibly  hydrastis  canadensis,  has  any  special  value.  The 
latter  is  said  to  have  some  power  to  control  hemorrhage.  Ergot  has 
some  value  in  controlling  hemorrhage,  and  thereby  preserving  the 
vitality  of  the  patient  until  relief  may  come  with  the  menopause  or 
after  surgical  removal.  The  drug,  if  long  continued,  is  not  well  borne 
by  the  stomach ;  hence  it  should  be  given  either  by  hypodermic 
injection  or  by  rectal  suppositories.  The  dose  is  determined  by  the 
effect.  If  used  at  all,  sufficient  should  be  given  to  control  the  bleed- 
ing. The  ice-bag  over  the  hypogastrium  to  some  extent  controls 
hemorrhage. 

2.  Manipulations. 

When  a  myoma  becomes  incarcerated  in  the  small  pelvis  under  the 
sacral  promontory  and  causes  pressure-symptoms,  the  indication  is  to 
force  it  up  into  the  abdomen  by  manipulation.  The  manipulation  is 
carried  out  best  with  the  patient  in  the  knee-breast  position,  the 
assumption  of  which  in  some  cases  will  cause  the  tumor  to  fall  out  of 
the  pelvis  by  force  of  gravity  alone.  In  other  cases  considerable 
pressure,  with  or  without  anaesthesia,  may  be  required  to  dislodge  it. 
The  tumor,  if  small  and  very  movable,  may  fall  back  readily  into  the 
pelvis  minor,  causing  great  mechanical  disturbance  and  necessitating 
daily  replacement.  If  the  tumor  from  any  cause,  such,  for  example, 
as  adhesions,  cannot  be  forced  up  into  the  abdomen  and  pressure- 
symptoms  are  urgent^  it  may  have  to  be  removed. 

380 


TUMORS  OF  THE   UTERUS— MYOMA.  381 

3.  Intra-uterine  Tamponade. 

When  hemorrhage  is  profuse  and  exhausting,  the  most  effective 
means  of  temporary  hsemostasis  is  intra-uterine  tamponade  made 
through  Sims'  or  Simon's  speculum.  A  continuous  strip  of  aseptic 
gauze  should  be  packed  tightly  into  the  uterus,  especially  into  the 
cervical  cavity,  and  renewed  every  forty-eight  hours  luitil  the  flow 
has  ceased.  In  this  way  an  exhausted  exsanguinated  patient  may  in 
a  few  weeks  regain  strength  to  endure  the  radical  operation.  This 
treatment  in  the  hands  of  the  author  has  in  one  case  been  followed  not 
only  by  entire  relief  of  menorrhagia,  but  also  by  almost  total  disap- 
pearance of  the  tumor.  The  tampon  was  used  during  three  consecu- 
tive menstruations,  and  the  tumor  was  reduced  from  the  size  of  a 
child's  head  to  that  of  a  hen's  g^^.  The  age  of  the  patient,  forty-five 
years,  and  the  near  approach  of  the  menopause  may  account  partially, 
at  least,  for  this  extraordinary  result. 

4.  Intra-uterine  Styptics. 

Churchill's  tincture  of  iodine,  solution  of  iron  persulphate,  the  10 
per  cent,  solution  of  antipyrin,  and  other  styptics,  may  be  injected  into 
the  uterus  for  the  control  of  hemorrhage.  These  agents,  especially 
the  iron  persulphate,  are  apt  to  form  hard  blood-clots,  which  may 
become  septic  and  therefore  dangerous.  The  method  is  altogether 
inferior  to  that  of  tamponade. 

5.  Electrolysis. 

The  observations  of  Vineberg  upon  the  statistics  of  Keith,  Engel- 
mann,  Gautier,  and  other  eminent  electro-therapeutists,  show  three 
hundred  and  seventy-two  cases  with  nine  reported  cures  and  five 
deaths — an  excessive  mortality  in  consideration  of  the  limited  number 
of  cures.  Galvanopuncture  and  electrolysis  in  fibrocysts  are  con- 
demned strongly.  The  earlier  promises  of  the  enthusiastic  supporters 
of,  electrolysis  have  not  been  fulfilled  ;  the  immediate  dangers  of  it 
also  are  considerable.  The  survival  of  the  electrical  method  in 
gynecology  depends  chiefly  upon  the  patient's  ignorance  of  its  inade- 
quacy and  dangers,  upon  her  worship  of  the  mysterious,  upon  an 
unreasoning  dread  of  operative  measures,  and  upon  a  desire  to  grasp 
any  other  promising  means  of  relief. 

6.  Expectant  Treatment. 

See  non-operative  prognosis  at  the  end  of  the  last  Chapter. 

SURGICAL  TREATMENT. 

It  would  be  unprofitable  to  enlarge  upon  a  great  variety  of  pro- 
cedures which  have  become  or  seem  destined  to  become  obsolete. 
The  more  useful  o]ierations  for  the  treatment  of  fibromyomata  of  the 
uterus  will  be  divided  as  follows  : 

1.  Palliative  operations. 

2.  Radical  vaginal  operations. 

3.  Radical  abdominal  operations. 

24 


382  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

1.  Palliative  Operations. 

The  only  palliative  operation  of  recognized  value  is  curettage. 

Curettage. — If  the  tumor  by  its  irritating  presence  gives  rise  to 
hemorrhagic  endometritis,  curettage  is  indicated  precisely  as  it  would 
be  in  hemorrhagic  endometritis  from  any  other  cause.  Generally  the 
operation  is  followed  by  some  relief  from  the  menorrhagia,  but  is 
seldom  permanent  in  its  results,  and  usually,  therefore,  must  be 
repeated  again  and  again.  It  is  especially  useful,  in  connection  with 
intra-uterine  gauze  tamponade,  to  control  hemorrhage  until  an  ex- 
hausted patient  can  gain  blood  and  strength  for  a  more  radical  opera- 
tion, or,  in  cases  of  small  tumors,  until  the  menopause  has  passed. 
The  technique  of  curettage  is  described  in  Chapter  V. 

Other  palliative  operations  have  been  proposed,  such,  for  example, 
as  ligature  of  the  uterine  and  ovarian  arteries ;  but  they  are  all  obso- 
lete with  the  possible  exception  of  removal  of  the  uterine  appendages ; 
this  procedure,  which  suggests  the  names  of  Battey,  Hegar,  and  Tait, 
when  properly  carried  out — i.  e.,  when  the  Fallopian  tubes  are  thor- 
oughly removed,  as  described  in  Chapter  XXIII. ,  and  when  the 
ligatures  are  placed  close  to  the  uterus  so  as  to  include  a  large  part 
of  the  broad  ligament — usually  checks  the  hemorrhage  and  reduces  the 
tumor,  sometimes  even  causing  it  to  disappear.  It  is,  however, 
nearly  if  not  quite  as  dangerous  as  the  more  radical  operations,  and  is 
now  obsolete  except  in  rare  cases  of  small  tumors  in  which,  for  some 
special  reason,  hysterectomy  and  myomectomy  are  inadvisable. 

2.  Radical  Vaginal  Operations. 

The  vaginal  operation  is  preferable  when  the  tumor  can  be  reached 
readily  by  that  route.  All  cervical  fibroids,  all  intra-uterine  pedun- 
culated fibroids,  and  some  of  the  more  accessible  submucous  fibroids, 
have  been  removed  usually  by  way  of  the  vagina.  In  their  removal 
the  ^craseur  and  galvanocautery,  so  often  used  for  hsemostasis,  are 
unnecessary,  because  the  hemorrhage  is  either  not  feared  or  can  be 
controlled  readily  by  the  uterine  tampon.  The  vaginal  route  usually 
has  been  reserved  for  tumors  of  a  size  not  larger  than  the  capacity  of 
the  small  pelvis. 

The  radical  vaginal  operations  are  :  A,  torsion  for  small  peduncu- 
lated intra-uterine  myomata ;  B,  vaginal  hysterectomy ;  C,  vaginal 
enucleation  and  morcellation. 

A.  Removal  of  Small  Pedunculated  Myomata. — When  the  uterus  is 
dilated,  either  by  uterine  contraction  on  the  tumor  or  by  instrumental 
means,  the  pedunculated  tumor  is  seized  by  the  vulsellum  forceps  or 
bullet  forceps,  drawn  down,  and  twisted  off  or  removed  by  the  scis- 
sors. The  uterus  then  is  packed  with  aseptic  gauze.  In  the  removal 
of  a  pedunculated  myoma  this  traction  on  the  growth  should  not  be 
very  strong,  for  the  uterine  wall  may  be  drawn  down  and  accidentally 
cut  through  in  the  removal  of  the  growth.  Fatal  peritonitis  has 
resulted  from  this  accident. 

B.  Vaginal  Hysterectomy. — When  numerous  small  tumors  are  scat-- 


TUMORS  OF  THE   UTERUS— MYOMA. 


383 


tered  throughout  the  uterus,  Figure  165,  and  the  number  is  so  large 
that  individual  enucleation  is  impossible,  and  when,  moreover,  the 
mass  is  not  too  large  to  be  delivered  through  the  vagina,  it  may  be 


Figure  169. 


Radical  vaginal  operation.    Morcellation  of  an  intra-uterine  myoma.    Emmet's  method. 


removed  entire  by  vaginal  hysterectomy.  Delivery  through  the 
vagina  sometimes  presents  unexpected  difficulties.  Preparation  should 
therefore  be  made  for  a  supplemental  abdominal  section. 


384  TUMORS,   TUBAL  PREGNANCY,   MALF0R3IATI0NS. 

C.  Vaginal  Enucleation  and  Morcellation. — Intranuiral  myoma, 
especially  if  situated  in  the  lower  segments  of  the  corpus  or  in  the 
cervix  uteri,  and  not  too  large,  may  be  enucleated  safely  and  removed 
through  the  vagina.  The  morcellation  method  has  been  used  often 
and  successfully  by  French  surgeons  for  the  removal  of  large  intra- 
mural tumors.  The  removal  is  accomplished  by  repeatedly  seizing 
the  presenting  part  of  the  tumor  with  the  vulselluni  forceps  and  cut- 
ting away  as  large  a  piece  as  possible  with  the  scissors,  one  piece  after 
another,  until  the  whole  tumor  has  been  removed.  This  is  the  opera- 
tion by  traction  and  morcellement  or  morcellation.  The  method, 
although  generally  supposed  to  be  of  more  recent  origin,  was  described 
virtually  by  Thomas  Addis  Emmet  more  than  thirty  years  ago,  and 
has  been  consistently  advocated  and  practised  by  him  ever  since. 
It  is  applicable  to  tliose  cases  in  which  the  tumor  is  accessible 
through  the  vagina,  but  is  too  large  to  be  enucleated  and  delivered 
entire. 

The  operation  of  traction  and  morcellation,  when  its  technique 
is  understood  more  generally  and  its  advantages  appreciated,  Avill 
become  undoubtedly  more  and  more  a  procedure  of  election  in  place 
of  hysterectomy.  Many  large  submucous  or  mural  tumors,  for  which 
the  abdomen  now  is  opened  and  the  uterus  sacrificed,  may  be  removed 
rapidly,  safely,  and  effectually  by  this  method. 

One  clear  contraindication  to  the  vaginal  route  must  always  be, 
however,  the  possible  presence  of  pus-tubes  or  ovarian  abscesses,  so 
often  unrecognized  or  unrecognizable  when  they  occur  in  connection 
with  large,  irregular  fibromyomata.  Many  times  an  unsuspected  pus- 
tube  has  been  ruptured  by  the  enucleation  or  morcellation  of  a 
myoma  through  the  vagina.  The  vaginal  route,  then,  should  be 
avoided  if  there  be  reason  to  suspect  purulent  disease  of  the  uterine 
appendages. 

Usually  the  tumor  is  made  more  accessible  and  enucleation  or 
morcellation  of  it  facilitated  by  dilatation  or  by  deep  lateral  incisions 
of  the  cervix,  even  to  the  internal  os.  These  incisions  having  been 
made,  the  anterior  and  posterior  lips  of  the  cervix  are  drawn  well 
down  to  the  vulva  and  held  widely  apart  by  means  of  strong,  double 
tooth-forceps  in  the  hands  of  an  assistant.  The  operator  then  seizes 
the  presenting  part  of  the  tumor  with  heavy  morcellation  tooth-for- 
ceps. Figure  169,  and  removes  it,  either  by  enucleation  or  by  mor- 
cellation. If  the  tumor  be  intramural,  it  may  be  necessary  to  divide 
the  mucous  membrane  and  subjacent  muscular  tissue  before  beginning 
the  enucleation. 

An  improvement  upon  the  two  lateral  incisions  mentioned  above  is 
a  simple  median  incision  through  the  anterior  wall  of  the  uterus  made 
as  follows  •} 

1.  Make  a  circular  incision  in  front  of  the  uterus  which  shall 
separate  the  vaginal  wall  from  the  cervix  at  the  uterovaginal  attach- 
ment, as  shown  in  Figures  170  and  171. 

1  Published  by  the  author  in  the  Transactions  Minnesota  State  Medical  Society,  1896,  and 
republished  in  the  Journal  of  the  American  Medical  Association,  August  15,  1896. 


TUMORS   OF  THE    UTERUS— MYOMA. 


385 


2.  Incise  the  anterior  vaginal  wall  from  the  middle  point  of  the 
first  incision  for  a  distance  of  about  one  inch,  taking  care  not  to 
invade  the  bladder  and  to  avoid  the  ureter  on  either  side.  These 
incisions  are  the  same  as  for  anterior  vaginal  section,  described  in 
Chapter  XXIII. 


FiGUKE   170. 


FiGUKE  171. 


Figure  170. — Radical  vaginal  operation.  Author's  incision.  Lines  indicating  the  vaginal 
incisions  to  expose  the  anterior  uterine  wall  prenaratory  to  dividing  it  with  scissors. 

Figure  171.— Author's  incision.  Making  longitudinal  division  of  anterior  wall  of  uterus, 
in  order  to  expose  the  field  of  operation  for  the  removal  of  a  myoma. 


3.  Separate  the  bladdt^r  from  the  uterus  by  means  of  the  fingers  or 
some  blunt  instrument,  keeping  close  to  the  uterus  until  the  peri- 
toneum is  reached,  but  not  divided.  Then  expose  with  retractors  or 
fingers  the  anterior  wall  of  the  uterus. 

4.  Divide  the  anterior  Avail  of  the  uterus  longitudinally  in  the 
median  line  by  means  of  scissors  to  whatever  extent  may  be  neces- 
sary to  render  the  tumor  accessible.  If  necessary,  the  peritoneum 
may  be  opened  and  the  incision  carried  up  into  the  corpus  uteri. 

This  simple  anterior  incision  permits  wide  separation  of  the  lateral 


386  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

fragments  of  the  anterior  uterine  wall,  and  thereby  exposes  the  endo- 
metrium, and  may  render  accessible  a  myoma  in  any  part  of  the 
uterus.  It  has  the  following  advantages  over  the  lateral  incisions  : 
1.  There  is  less  traumatism — one  incision  instead  of  two.  2.  The 
parametria  are  not  opened  and  exposed  to  possible  sepsis.  3.  The 
tumor  is  more  accessible  because  the  anterior  uterine  wall  is  out  of 
the  way,  instead  of  being  between  the  operator  and  the  field  of  ope- 
ration. 4.  A  much  longer  incision  may  be  made,  if  necessary,  because 
the  broad  ligaments  are  not  involved.  5.  There  is  less  hemorrhage. 
6.  The  pelvic  cavity  may  be  reached  easily  through  this  incision  tor 
any  further  operation  on  the  uterine  appendages  or  peritoneum.  Even 
a  small  pedunculated  subperitoneal  tumor  may  be  removed  through 
this  incision. 

3.  Radical  Abdominal  Operations. 

Radical  abdominal  operations  are  adapted  to  large  subperitoneal 
and  intramural  tumors  which  cannot  be  removed  well  through  the 
vagina.     They  are : 

1.  Myomectomy — removal  of  the  tumor  without  sacrificing  any 
part  of  the  uterus. 

2.  Supravaginal  hysteromyomectomy — removal  of  the  tumor 
together  with  the  corpus  uteri  and  the  supravaginal  portion  of  the 
cervix  uteri. 

3.  Complete  hysteromyomectomy — removal  of  the  tumor  and  the 
entire  uterus. 

1.  Abdominal  Myomectomy. 

Abdominal  myomectomy — removal  of  the  tumor  without  sacri- 
ficing any  part  of  the  uterus — is  indicated  for  the  tumors  mentioned 
below  under  o,  6,  and  c. 

a.  Pedunculated  subperitoneal  tumors.     Figure  172. 

6.  Small  intramural  and  subserous  tumors,  when  the  growths  can 
be  removed  with  slight  traumatism  and  the  uterine  wound  closed  with 
interrupted  or  continuous  catgut  sutures.  Figures  173  and  174.  An 
improvement  on  the  interrupted  and  continuous  sutures  is  the  purse- 
string  suture  shown  in  Figures  175  to  178,  which  has  the  following 
advantages  :  1,  rapidity  of  application  ;  2,  ready  and  reliable  hsemo- 
stasis  ;  3,  slight  traumatism. 

c.  Some  large  intramural  and  subserous  tumors  which  can  readily 
be  enucleated — shelled  out — and  the  uterine  wounds  closed  with  or 
without  drain.     Figures  179  aud  180. 

The  growths  indicated  under  a  and  b  may  be  treated  easily  and 
safely  by  enucleation  and  suture. 

The  larger  growths  indicated  under  c,  even  though  lying  deep  in 
the  uterine  wall  or  broad  ligament,  in  many  cases  may  be  "  shelled 
out"  with  the  greatest  ease,  and  the  tumor-cavities  from  which  they 
have  been  removed  may  be  closed  successfully  and  obliterated  by 
buried  sutures ;  or,  if  the  surfaces  are  too  extensive  to  be  treated 
safely  by  buried  sutures,  the  cavities  may  be  drained,  and  in  this  way 
finally  obliterated.     Figures  179  and  180  show  the  method  of  drain- 


TUMORS  OF  THE   UTERUS- MYOMA. 


387 


age  and  suture.  While  a  large  growth  is  being  enucleated  and  the 
uterine  wound  closed  hemorrhage  may  be  controlled  by  a  temporary 
rubber  ligature  placed  around  the  lower  segment  of  the  uterus.  Before 
closing  the  abdominal  wound  this  ligature  is  removed,  and  a  little 
time  is  allowed  to  make  sure  that  there  is  to  be  no  hemorrhage  from 
the   uterine    wound.      Hemorrhage    usually   is   controlled    in    great 

Figure  172. 


/ 


Myomectomy.    Pedunculated  myoma  removed  :   wound  being  closed  by  continuous  catgut 

suture. 

measure  by  the  uterine  contraction  which  follows  enucleation.  The 
mortality  of  this  method  for  small  tumors,  in  which  the  traumatism 
is  slight,  is  surprisingly  small. 

In  case  of  a  large  intramural  tumor,  and  extensive  traumatism  Avith 
enormous  surfaces  to  be  united  by  buried  sutures,  the  method  of 
abdominal  myomectomy  as  above  described  involves  great  danger  of 
sepsis  and  secondary  hemorrhage,  and  should  give  place  to  hystero- 


388 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


myomectomy  or  be  modified  by  the  introduction  of  drainage  as  fol- 
lows : 

Figure  173. 


Myomectomy.  Uterus  with  eight  myomata  to  be  removed  and  one  being  removed.  The 
number  of  myomata  here  shown  is  larger  than  should  ordinarily  be  removed  by  this  method.  Unless  they  are 
very  small  and  subperitoneal,  hysterectomy  would  be  safer. 

Drainage  in  Abdominal  Myomectomy, — After  the  tumor  has 
been  enucleated   an  opening   is  made  from  the  tumor-cavity  to  the 

Figure  174. 


Myomectomy :  usual  method  of  suture.    Same  uterus  as  shown  in  Figure  166.    Shows  method 
of  closing  wounds  made  by  removal  of  myomata ;  continuous  catgut  sutures. 


uterine  cavity.  If  the  uterine  canal  is  patulous,  a  continuous  strip  of 
gauze  is  carried  from  the  tumor-cavity  directly  through  into  the 
vagina,  the  tumor-cavity  being  packed   with   the   same   continuous 


TUMORS  OF  THE    UTERUS— MYOMA. 


389 


strip.  The  temporary  elastic  ligature  around  the  uterus  does  not 
interfere  with  the  introduction  of  the  gauze.  The  uterine  wound 
then  is  closed  with  deep  catgut  sutures,  the  peritoneal  margins  being 
turned  in  and  united,  as  shown  in  Figure  179,  so  that  the  whole 
uterine  traumatism,  now  isolated  from  the  peritoneum,  may  be  drained 
adequately  through  the  vagina.    If  the  uterine  canal  is  not  sufficiently 


Figure  175. 


Figure  176. 


Figure  177. 


Figure  178. 


Figure  175. — Author's  operation,  first  step.  Purse-string  ligature  in  place  around  the 
myoma  which  is  to  be  removed. 

Figure  176.— Second  step.    Capsule  split  and  myoma  exposed. 

Figure  177.— Third  step.    Enucleation  of  myoma. 

Figure  178.— Final  step.  Fundus  uteri.  One  myoma  has  been  removed,  and  wound  eloised 
by  tying  purse-string  ligature.  Another  myoma  has  been  removed,  and  purse-string  ligature  is 
being  tied. 


patulous  to  admit  the  gauze,  it  may  be  dilated  or  the  walls  of  it  may 
be  incised  anteriorly  and  posteriorly  by  means  of  a  herniotomy-knife, 
or  it  may  be  both  dilated  and  incised.  The  vagina  is  filled  loosely 
with  gauze  to  meet  that  which  protrudes  from  the  uterus,  and  the 
vulva  is  covered  by  a  gauze  pad,  to  be  changed  as  often  as  it  becomes 
moist.  The  gauze  should  be  removed  in  two  or  three  days.  Care  is 
necessary  in  the  closure  of  the  uterine  wound  tliat  the  gauze  be  not 


390 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


caught  in  a  suture,  because  then  removal  would  have  to  be  postponed 
until  after  absorption  of  the  suture. 

An  intraligamentous  myoma  may  be  shelled  out  readily  from  its 
bed  between  the  folds  of  the  broad  ligament.  These  same  principles 
of  drainage  apply  as  in  the  case  of  intramural  tumors,  except  as  to  the 
route  of  drainage,  which  should  be,  not  through  the  uterine  canal,  but 
through  an  opening  which  is  made  readily  from  the  tumor-cavity  to 
a  point  in  the  vagina  just  back  of  or  in  front  of  the  uterus.  In 
exceptional  cases  it  may  be  necessary  for  purposes  of  hsemostasis  to 
ligature  the  ovarian  or  uterine  artery,  or  both.     Experience  has  shown 


Figure  179. 


Myomectomy.  An  intramural  myoma  has  been  enucleated ;  an  opening  has  been  made 
between  the  tumor-cavity  and  the  endometrium ;  uterovaginal  gauze  drain  ;  uterine  wound 
closed  by  suture.    The  opening  iu  the  uterine  wall  is  intended  to  show  the  gauze. 

that  sloughing  of  the  uterus  from  thus  cutting  off  this  blood-supply  is 
not  to  be  feared.     See  Figures  179  and  180. 

Intra-abdominal  closure,  with  vaginal  drainage  of  the  tumor-cavity, 
was  suggested  early  by  August  Martin,  but  he  appears  not  to  have 
practised  the  method  extensively. 

The  author's  experience  since  1889  with  the  above  technique 
shows  :  first,  almost  entire  freedom  from  mortality  ;  second,  prompt 
and  uneventful  recovery  ;  third,  the  most  gratifying  permanent  results. 
The  method  is  undoubtedly  applicable  to  a  much  larger  number 
of  tumors  than  generally  is  supposed.  Removal  of  the  uterus  for 
myoma  is  often  necessary,  but  not  so  often  as  statistics  would  indicate. 


TUMOftS  OF  THE   UTERUS— MYOMA. 


391 


In  the  majority  of  cases  the  uterine  appendages  will  be  found  normal, 
and  in  a  large  proportion  of  this  majority  the  tumor  may  be  enucleated 
and  the  wound  successfully  closed,  precisely  as  would  be  done  for  the 
removal  of  such  a  tumor  in  any  other  part  of  the  body.  Cases  of 
very  large  tumors,  and  cases  in  which  many  small  tumors  are  scattered 
through  the  uterine  wall,  will  require  hysterectomy ;  but  the  con- 
servative operation  of  simple  enucleation  often  will  be  indicated  when 
the  tumor  is  even  larger  than  the  foetal  head,  and  in  cases  of  multiple 
myomata  when  there  are  not  too  many  tumors.  The  preservation  of 
a  non-infected  uterus,  even  when  the  appendages  have  to  be  removed, 
is  desirable. 

Figure  180. 


Myomectomy.  Intraligamentous  myoma  has  been  removed  from  space  between  folds  of 
broad  ligament.  Gauze-drain  from  this  space  through  an  opening,  made  for  the  purpose,  direct 
into  the  vagina. 

Drainage  of  the  tumor-cavity  by  stitching  it  into  the  abdominal 
wound  and  packing  it  with  gauze^  has  been  carried  out  successfully  in 
many  cases.  The  vaginal  route  for  drainage,  however,  offers  decided 
advantages,  and  therefore  usually  will  be  preferred.^ 

2.  Supravaginal  Hysteromyomectomy. 

Supravaginal  hysteromyomectomy  is  removal  of  the  tumor,  the 
corpus  uteri,  and  the  supravaginal  portion  of  the  cervix,  through  an 
abdominal  incision,  leaving  no  part  of  the  uterus  except  the  vaginal 
portion  of  the  cervix. 

Disinfection  of  the  Vagina. — An  imperative  measure,  prelimi- 
nary to  this  operation,  is  scrupulous  disinfection  of  the  vagina  and  the 
external  genitals.  After  the  usual  cleansing  of  the  vagina,  as  de.scribed 
in  Chapter  IL,  the  vagina  should  be  packed  lightly  but  in  all  its  parts 
with  gauze  saturated  with  a  70  per  cent,  alcoholic  solution  of  mercuric 

•  Polk.    E.  C.  Dudley.    Senn. 

-The  author  used  uterovaginal  drainage  in  myomectomy  in  April,  1889;  his  first  case  was 
reported  in  the  American  Journal  of  Obstetrics,  September,  1889. 


392  TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS. 

bichloride.  This  is  most  essential  as  an  aseptic  measure,  especially  in 
view  of  the  possibility  that  an  opening  for  drainage  may  have  to  be 
made  from  the  pelvic  cavity  into  the  vagina. 

Technictue  of  Supravaginal  Hysteromyomectomy. — The  usual  opera- 
tion is  to  secure  the  ovarian  and  uterine  arteries  by  means  of  strong 
catgut  ligatures,  and  after  removal  of  the  tumor,  corpus  uteri,  and 
supi^avaginal  portion  of  the  cervix,  to  close  the  uterine  stump  by 
means  of  a  continuous  suture  running  from  side  to  side,  and  then  to 
close  the  wound  in  the  broad  ligaments  by  means  of  another  continu- 
ous suture  also  running  in  the  same  direction.  See  Figure  174. 
This  method  is  open  to  the  following  objections:  1.  The  severed  broad 
ligaments  retract  to  the  sides  of  the  pelvis,  where  they  can  no  longer 
give  adequate  support  to  the  bladder,  vagina,  and  rectum ;  the  fre- 
quent consequence  is  exaggerated  descent  of  the  pelvic  floor  with 
disabling  and  permanent  cystocele  and  rectocele.  2.  The  rectum  and 
bladder  are  brought  into  close  relations  with  only  a  thin  wall  between, 
so  that  the  possibility  of  infection  from  one  to  the  other  is  increased. 
3.  In  many  cases  the  bladder  is  drawn  over  the  uterine  stump  in 
order  to  cover  it ;  this  may  give  rise  to  mechanical  irritation  of  the 
bladder. 

The  author  has  attempted  to  overcome  the  difficulties  above  men- 
tioned by  closing  the  uterine  stump  in  the  anteroposterior  direction 
and  by  end-to-end  approximation  of  the  broad  ligaments.  A  descrip- 
tion of  end-to-end  approximation  will  be  found  in  Figures  182  to 
192.     The  steps  of  supravaginal  hysteromyomectomy  are  as  follows : 

A.  Abdominal  incision. 

B.  Delivery  of  the  tumor  through  the  abdominal  wound. 

C.  Ligature  of  the  ovarian  and  uterine  arteries,  and  removal  of 

the  tumor  together  with  the  corpus  uteri  and  supravaginal 
portion  of  the  cervix  uteri. 

D.  Toilet  of  the  peritoneum. 

E.  Closure  of  the  abdominal  wound. 

A.  In  case  of  a  large  tumor  the  abdominal  incision  should  be 
made  nearer  the  umbilicus  than  the  pubes,  to  avoid  the  bladder,  which 
by  the  growth  of  the  tumor  not  infrequently  is  drawn  up  out  of  the 
pelvis.  The  incision,  first  exploratory — that  is,  large  enough  to  admit 
one  or  two  fingers — may  be  enlarged  sufficiently  to  permit  delivery  of 
the  tumor. 

B.  Delivery  of  the  tumor  through  the  abdominal  wound  is 
effected  sometimes  by  pressure  on  the  abdominal  walls  around  the 
incision,  so  as  to  squeeze  it  out  as  one  would  squeeze  pus  out  after 
opening  an  abscess.  Usually,  however,  the  tumor  is  delivered  by 
traction  with  the  hands  or  with  heavy  vulsellum  forceps.  In  many 
cases  the  tumor  is  fixed  so  firmly  in  the  pelvis  that  it  cannot  be 
brought  through  the  abdominal  wound  until  after  some  of  the  press- 
ure-forceps or  ligatures  have  been  placed  around  the  arteries  and  the 
mass  partially  severed  from  the  broad  ligaments.  If  the  abdominal 
incision  has  been  very  long,  and  the  intestines  are  much  inclined  to 
protrude  through  the  wound,  they  may,  as  soon  as  the  tumor  has  been 
brought  through,  be  held  back  by  a  large  flat  gauze  pad  or  by  suture 


TUMORS  OF  THE   UTERUS— MYOMA.  393 

of  the  upper  part  of  the  wound.  It  is  clearly  important  to  prevent 
protrusion  of  the  intestine,  and  thereby  to  lessen  exposure  of  the 
peritoneum. 

C.  In  a  majority  of  all  cases  of  hysteromyomectomy,  whether 
complete  or  incomplete,  the  operation  may  be  facilitated  by  the  use 
of  long-bladed  forceps  to  secure  temporary  hsemostasis  of  the  uterine 
and  ovarian  arteries  during  removal  of  the  mass,  and  to  be  sub- 
stituted by  ligatures  as  soon  as  the  mass  has  been  removed.  See 
Figures  182  to  186.  This  use  of  the  forceps  will  enable  the  operator 
to  get  the  tumor  rapidly  out  of  the  way,  and  to  complete  the  opera- 
tion with  great  speed,  and  during  the  operation  to  avoid  hemorrhage. 
Figures  182  to  184  show  the  forceps  in  place.  The  further  steps  of 
this  part  of  the  operation  are  as  follows  : 

1.  Clamp  the  arteries  as  shown  in  the  diagrams  ;  the  outer  forceps 
siuit  oif  the  ovarian  artery  as  it  passes  inward  through  the  broad  liga- 
ment toward  the  uterus  ;  the  inner  forceps  prevent  reflex  hemorrhage 
from  the  utero-ovarian  anastomosis  at  the  uterine  end  of  the  broad 
ligament. 

2.  Divide  the  broad  ligaments  by  means  of  scissors. 

3.  Divide  the  peritoneal  investment  of  the  uterus  all  around  the 
cervix  just  above  the  bladder  attachment ;  this  is  done  best  by  lightly 
cutting  around  the  uterus  with  a  scalpel  or  pointed  scissors. 

4.  Strip  the  circumuterine  peritoneum  together  with  the  attached 
bladder  down  toward  the  vaginal  portion  of  the  cervix  to  the  region 
of  the  uterine  arteries.  During  the  stripping  off  of  the  bladder  the 
relations  of  it  may  be  recognized  by  a  sound  in  the  bladder.  The 
stripping  is  accomplished  best  by  means  of  gauze  pressure ;  it  is  like 
a  blunt  dissection. 

5.  Clamp  the  uterine  arteries  by  means  of  forceps  or  ligate 
them  at  once ;  in  applying  the  ligatures,  care  is  necessary  to  avoid 
the  ureters,  which  sometimes  run  very  close  to  the  uterus.  Some 
operators  take  the  precaution  to  have  a  catheter  in  each  ureter  in  order 
to  keep  track  of  it  during  the  operation. 

6.  Remove  the  tumor  and  all  the  uterus  except  the  vaginal  por- 
tion by  means  of  a  wedge-shaped  incision  so  directed  that  the  uterine 
stump  may  be  sutured  in  a  line  running  from  before  backward,  not 
from  side  to  side. 

7.  Place  permanent  ligatures  on  the  ovarian  and  uterine  arteries 
and  remove  the  pressure-forceps.  It  is  important  that  the  forceps  be 
loosened  by  an  assistant  while  the  ligatures  are  being  drawn  tight, 
liecause  if  tied  before  the  forceps  are  removed  dangerous  hemorrhage 
may  result.  The  uterine  arteries  are  located  sometimes  by  sight, 
sometimes  by  touch,  and  accordingly  are  secured  by  ligature,  isolated 
or  en  masse.  The  ovarian  artery  usually  is  tied  en  masse.  In  tying 
either  the  ovarian  or  uterine  arteries  en  masse,  it  is  of  great  importance 
to  place  the  ligatures  so  that  the  ligatured  pjart  will  not  be  deprived 
ivholly  of  circulation — that  is,  so  that  it  will  receive  collateral  circulation 
— and  therefore  not  be  subject  to  necrotic  processes.  Figures  188  to  192 
show  the  ligatures,  ichich  have  been  applied  in  such  a  manner  as  not  to 
produce  necrosis  of  the  stump. 


394  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS. 

In  some  cases  tlie  tumor  so  fills  the  pelvis  that  the  forceps,  for 
lack  of  room,  cannot  be  applied.  Then,  an  elastic  ligature  having 
been  thrown  rapidly  around  the  cervix  for  temporary  hsemostasis,  the 
tumor  may  be  enucleated  and  the  size  of  the  mass  so  reduced  that  the 
forceps  may  be  applied.  As  the  incusion  is  carried  down  through  the 
broad  ligament  on  each  side  additional  forceps,  if  needed  to  control 
hemorrhage,  may  be  used  until  the  entire  mass — tumor,  corpus  uteri, 
and  supravaginal  portion  of  the  cervix — has  been  removed;  then  per- 
manent ligatures  on  the  ovarian  and  uterine  arteries  and  on  bleeding 
points  should  be  substituted  for  the  forceps. 

D.  The  toilet  of  the  peritoneum,  which  consists  of  the  following 
steps  : 

1 .  Ligature  of  any  bleeding  points. 

2.  Cauterization  of  the  remaining  portion  of  the  cervical  canal  with 
95  per  cent,  carbolic  acid ;  this  may  be  applied  on  a  probe  or  grooved 
director.  Sponges  and  instruments  used  in  connection  with  the  cervi- 
cal canal  should  for  reasons  of  asepsis  not  be  used  elsewhere. 

3.  If  the  case  is  simple  and  requires  no  vaginal  drain,  the  cervical 
stump  should  be  closed  by  a  line  of  sutures  running  in  the  antero- 
posterior direction,  and  the  broad  ligaments  should  be  closed  by  end- 
to-end  approximation,  as  described  in  Figures  185,  186,  and  187.  If 
there  is  fear  of  possible  sepsis  in  connection  with  the  vaginal  wound, 
or  other  reason  to  use  vaginal  drainage,  the  walls  of  the  remaining 
portion  of  the  cervix  should  be  split,  as  shown  in  Figure  188,  and  a 
continuous  strip  of  sterile  gauze  should  be  passed  from  the  pelvic 
cavity  between  the  fragments  of  the  cervix  into  the  vagina,  as  shown 
in  Figure  189.  This  strip  should  fill  the  vagina  loosely  and  present 
at  the  vulva,  and  should  be  removed  about  two  days  after  the  opera- 
tion, and  the  removal  of  it  should  be  followed  by  gentle  low  pressure, 
vaginal  douches,  0.5  of  1  per  cent,  lysol  in  sterile  water.  The  vaginal 
wound  should  be  closed  as  indicated  in  Figures  189  and  190. 

E.  The  abdominal  wound  should  be  closed  without  drain  in  the 
usual  manner,  as  described  in  Chapter  VI. 

3.  Complete  Abdominal  Hysteromyomectomy. 

The  removal  of  the  entire  myomatous  uterus  is  indicated  :  first, 
when  the  uterus  is  septic  or  otherwise  so  diseased  as  to  render  the 
presence  of  any  part  of  it  unsafe  ;  second,  when  on  account  of  exten- 
sive traumatism  or  suppuration  vaginal  drainage  is  required.  In 
addition  to  the  above  indications  there  is  a  certain  legitimate  latitude 
of  choice,  so  that  the  bias  of  the  operator  properly  may  be  in  the 
direction  of  complete  hysterectomy.  The  operation  demands  the 
same  antiseptic  preparation  as  already  laid  down  for  supravaginal 
hysteromyomectomy. 

Technique  of  Complete  Abdominal  Hysteromyomectomy. — The  ab- 
dominal incision  ;  the  delivery  of  the  tumor ;  the  clamping  and  liga- 
ture of  the  arteries  ;  the  division  of  the  broad  ligaments  ;  and  the 
closure  of  the  wounds,  both  pelvic  and  abdominal,  are  substantially 
the  same  as  already  described  for  supravaginal  hysteromyomectomy. 


Figure  181 ' 


Supravaginal  Hysteromyomectomy.  Ordinary  method  of  closing  broad  ligaments. 
The  ovarian  and  uterine  arteries  have  been  secured  by  means  of  strong  catgut  ligatures, 
the  uterine  stump  has  been  closed  by  a  continuous  suture  running  from  side  to  side,  and  the 
wound  in  the  broad  ligaments  is  being  whipped  together  by  a  continuous  catgut  suture. 
The  ligatures  on  the  uterine  arteries  are  covered  in  by  peritoneum,  those  on  the  ovarian 
arteries  are  not  so  covered. 

A  better  method  of  securing  the  broad  ligaments  by  end-to-end  approximation  is  described 
in  the  following  figures,  182  to  192. 


'  This  series  of  illustrations.  Figures  181  to  192,  with  text,  were  published  by  the  author 
in  the  Journal  of  the  American  Medical  Association,  December,  1906.  A  similar  series  also 
was  published  in  the  same  journal,  March  29,  1902. 


395 


Figure  182 


Supravaginal  Hysterectomy.  Median  incision.  Abdominal  wound  held  apart  by 
retractor.  Myomatous  uterus  delivered  through  the  wound.  Broad  ligament  on  either 
side  clamped  by  two  long  forceps  preparatory  to  supravaginal  amputation  of  the  uterus. 
Cervix  uteri  between  the  tips  of  forceps.     Bladder  in  front. 


396 


Figure  183 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  A  transverse  incision  has  been 
made  in  front  of  the  cervix  uteri  at  the  vesical  reflexion,  each  end  terminating  where  the 
broad  ligament  joins  the  uterus.  A  similar  incision  has  been  made  through  the  peritoneum 
on  the  posterior  wall  of  the  uterus,  but  on  a  line  rather  higher  than  the  one  on  the  front.  The 
bladder  has  been  stripped  away  from  the  cervix  as  far  down  as  possible  by  the  same  kind 
of  sponge  pressure  as  shown  in  Figure  358.  The  posterior  peritoneum  has  been  stripped 
down  toward  the  vaginal  portion  of  the  cervix  in  the  same  manner.  The  broad  ligament 
has  been  divided  on  either  side  between  the  forceps,  and  the  utero-ovarian  anastomosis 
has  been  clamped  by  an  additional  forceps. 


397 


Figure  184 


Supravaginal  Hysterectomy.  (SemidiagrammaticO  The  myomatous  corpus  uteri 
is  being  cut  from  the  cervix  by  means  of  scissors.  Observe  the  triangular  incision  is  directed 
not  in  the  lateral,  but  in  the  anteroposterior  direction.  The  tumor  having  been  removed, 
the  next  step  will  be  to  secure  the  uterine  and  ovarian  arteries  by  means  of  catgut  ligatures 
on  either  side.  This  having  been  done  the  forceps,  are  to  be  removed.  The  broad  ligaments 
and  the  two  sides  of  the  cervical  stump  are  then  to  be  brought  together. 


398 


Figure  185 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  Looking  down  on  the  cervical 
stump  and  severed  broad  ligaments  instead  of  looking  at  the  anterior  wall  of  the  cervix, 
as  in  Figure  184.  Uterine  and  ovarian  arteries  secured  by  ligature.  Two  running  catgut 
sutures  catching  up  the  peritoneal  covering  of  the  cervical  stump  and  of  the  broad  liga- 
ments, one  anterior  and  one  posterior  to  the  cervix  and  broad  ligament.s,  have  been 
passed  in  such  a  manner  that  when  tied  they  will  draw  into  apposition  the  two  lateral 
surfaces  of  the  cervical  stump  and  will  unite  the  ligaments  end  to  end. 


399 


Figure  186 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  The  posterior  continuous  suture 
shown  in  Figure  185  has  been  drawn  taut  and  tied.  The  anterior  suture  is  being  drawn 
taut  preparatory  to  tying. 


400 


Figure  187 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  The  broad  ligaments  having  been 
drawn  together  as  shown  in  Figure  186,  the  approximation  is  completed  by  an  additional 
running  catgut  suture  beginning  at  the  lower  end  of  the  line  of  union  on  the  posterior  side 
of  the  united  ligaments  and  continuing  over  the  edge  of  the  ligaments  down  on  the  anterior 
surface  to  the  bladder.     This  completes  the  closure  of  the  pelvic  wound. 


401 


Figure  188 


Supravaginal  Hysterectomy.  The  corpus  uteri  ha?;  been  removed,  as  shown  in  Figure  184. 
The  uterine  and  ovarian  arteries  have  been  tied  with  catgut.  The  cervical  stump  is  being 
held  up  and  steadied  by  two  forceps  and  divided  anteroposteriorly  into  two  equal  lateral 
fragments  clear  to  the  vagina  by  means  of  scissors.  In  a  very  short,  easily  dilatable,  patulous 
cervix  the  uterine  dilator  introduced  from  above  downward  might  be  used  to  divulse  the 
cervical  canal  widely  in  place  of  cutting  with  scissors. 


402 


Figure  189 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  The  cervix  having  been  divided  or 
dilated  as  explained  in  the  legend  of  Figure  188,  a  short  strip  of  gauze  is  introduced  from 
above  downward  into  the  vagina.  The  two  fragments  of  the  cervix  and  the  cut  ends 
of  the  broad  ligaments  are  then  ready  to  be  united  by  sutures.  The  first  suture  is  intro- 
duced, but  not  tied.  The  operator  may  use  the  same  form  of  suture  as  shown  in  Figures 
185,  186,  and  187,  or  may  adopt  any  other  form  which  the  case  may  require. 


403 


PlGUHE    190 


Supravaginal  Hysterectomy.  (Semidiagrammatic.)  Continuation  of  Figure  189. 
Vaginal  gauze  drain.  End-to-end  approximation  of  the  broad  ligaments  by  continuous 
suture.  This  suture  is  here  intended  to  suggest  a  method  of  closure.  Other  forms  of  suture 
and  methods  of  closure  are  permissible. 


404 


Figure  191 


Complete  Hysterectomy.  (Semidiagrammatic.)  The  myomatous  corpus  having  been 
removed  and  the  cervix  spHt,  the  two  lateral  fragments  are  being  removed  by  means  of 
scissors,  care  being  taken  to  keep  close  to  the  cervix  in  order  to  avoid  the  ureters. 


405 


Figure  192 


Complete  Hysterectomy.  (Semidiagrammatic.)  Continuation  of  Figure  191.  The 
cervical  stump  having  been  removed,  the  cut  edge  of  the  vagina  is  drawn  up  by  means  of 
forceps  and  included  in  a  continuous  suture,  which  closes  the  upper  end  of  the  vagina 
against  the  united  broad  ligaments  which  are  brought  together  end  to  end.  This  form 
of  suture  is  here  introduced  to  show  a  method  of  union.  Other  forms  of  suture  may  be 
better  suited  to  individual  cases. 


406 


TUMORS  OF  THE   UTERUS— MYOMA.  407 

Certain   peculiarities  iu  technique,  however,  should  be  observed  as 
follows  : 

When  the  cervix  is  accessible  through  the  vagina,  the  first  incisions 
may  be  made  as  for  vaginal  hysterectomy,  the  bladder  and  the  rectum 
being  stripped  away  from  the  cervix,  if  practicable,  as  far  as  the 
peritoneal  cavity.  Tlie  broad  ligaments  may  be  separated  through 
the  vagina  and  tied  oif  as  high  in  some  cases  as  the  uterine  arteries. 
The  extent  to  which  this  can  be  done  will  vary  with  the  individual 
case.  The  vagina  now  is  packed  temporarily  with  a  continuous  strip 
of  gauze  saturated  with  a  1  :  3000  70  per  cent,  alcoholic  solution  of 
mercuric  bichloride.  The  final  renioval  of  the  uterus  through  the 
abdomen  is  facilitated  greatly  by  even  a  small  amount  of  vaginal 
detachment.  The  abdomen  then  is  opened  and  the  operation  continued 
as  already  described  for  supravaginal  hysterectomy  ;  the  uterine  arte- 
ries usually  are  clamped  and  tied  a  little  further  from  the  uterus. 
This  necessitates  the  greatest  care  not  to  include  the  ureters,  which 
cross  the  arteries  very  near  the  uterus.  The  broad  ligaments  and 
circumuterine  structures  then  are  divided  by  means  of  strong  scissors  ; 
in  making  the  incisions  for  this  purpose  close  to  the  uterus,  no  harm 
is  done  if,  on  either  side,  a  small  portion  of  the  lateral  wall  of  the 
cervix  uteri  be  left  behind.  The  bladder  is  stripped  away  from  the 
cervix  as  far  toward  the  vagina  as  practicable,  and  the  peritoneum  of  the 
posterior  wall  of  the  uterus  is  stripped  or  dissected  off  in  the  same  way. 

If  the  vaginal  incisions  previously  have  extended  into  the  pelvic 
cavity,  the  final  removal  of  the  uterus  will  be  easy.  If  the  incisions 
have  not  extended  so  far,  the  removal  will  not  be  difficult;  but  if  no 
vaginal  incisions  have  been  made,  the  operator  may  in  some  cases  find 
it  quite  tedious,  if  not  difficult,  to  work  his  way  down  into  the  vagina. 
The  attempt  has  resulted  occasionally  in  opening  the  rectum,  bladder, 
or  ureter.  This  difficulty  may  be  overcome  largely  by  a  simple 
device  which  has  been  used  by  the  author  for  several  years  with  great 
satisfaction  ;  the  operation  is  performed  as  follows  : 

The  bladder  having  been  stripped  off"  from  the  cervix  as  far  down 
as  possible  toward  the  vagina,  the  uterus  is  drawn  by  means  of  vul- 
sellum  forceps  well  up  through  the  abdominal  wound.  This  traction 
exposes  the  anterior  wall  of  the  cervix,  which  now  is  divided  freely 
with  sharp  scissors  by  a  longitudinal  incision  and  the  cervical  canal 
thereby  laid  open.  One  blade  of  the  scissors  is  passed  directly  down 
through  the  external  os  to  the  vagina,  dividing  the  entire  anterior 
cervical  wall.  The  finger  now  readily  passes  to  the  vagina,  and  serves 
as  a  guide  for  the  rapid  removal  of  the  uterus  by  a  circular  incision 
around  the  cervix  at  the  uterovaginal  attachment.  In  some  cases  it 
is  convenient  to  reserve  the  ligature  of  the  uterine  arteries  to  this  part 
of  the  operation.  Small  bleeding  vessels  are  tied  or  twisted.  Figure 
191. 

If  drainage  of  the  pelvic  cavity  is  required,  it  should  be  vaginal, 
and  the  vaginal  wound  should  be  left  open  or  partly  open  for  this 
purpose.  The  drain  is  introduced  as  follows :  the  end  of  a  long  strip 
of  gauze,  double  thick  and  two  inches  wide,  is  passed  from  the  pelvis 
through  the  vaginal  wound  to  the  vulva  ;  then  the  gauze  is  packed 


408  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

lightly  from  below  upward,  so  as  to  fill  the  vagina  and  the  vaginal 
wound,  and  to  cover  all  surfaces  in  the  pelvis  left  exposed  by  the 
operation.  The  dressing  over  the  vulva  which  receives  the  capillary 
drainage  from  the  gauze  should  be  kept  dry  by  frequent  changing. 
The  gauze  drain,  being  a  continuous  strip,  may  be  removed  easily 
through  the  vagina  in  two  or  three  days. 

If  drainage  is  not  required,  the  wound  should  be  closed  com- 
pletely both  on  the  vaginal  and  the  peritoneal  side.  This  may  be 
done  by  lines  of  union  from  side  to  side,  as  shown  in  Figure  192,  or 
by  end-to-end  approximation  of  the  broad  ligaments  as  already  de- 
scribed for  supravaginal  hysterorayomectomy.  Figure  192  shows 
the  upper  cut  end  of  the  vagina  closed  by  side-to-side  union,  and  the 
peritoneal  part  of  the  wound  closed  by  end-to-end  approximation  of 
the  broad  ligaments.  If  end-to-end  approximation  is  employed,  the 
same  sutures  that  unite  that  part  of  the  broad  ligaments  nearest  to  the 
vaginal  wound  should  also  catch  up  the  upper  cut  end  of  the  vagina 
so  as  to  draw  it  into  the  space  from  which  the  cervix  has  been  excised, 
and  unite  it  to  the  loM'er  portion  of  the  broad  ligament  stumps  at  or 
near  the  point  where  the  ligatures  surround  the  uterine  arteries ;  this 
serves  to  draw  the  vagina  strongly  upward  and  to  cover  the  exposed 
surfaces  between  the  vagina  and  broad  ligaments. 

Upon  completion  of  the  operation  the  vagina  should  be  packed 
with  gauze  from  the  vaginal  wound  to  the  vulva,  and  a  large  gauze 
dressing  placed  over  the  vulva  to  absorb  any  wound  secretions,  and 
held  there  by  a  T-bandage,  and  changed  often  to  keep  it  dry ;  the 
vaginal  gauze  is  removed  in  about  three  days,  after  which  low  pres- 
sure vaginal  douches  of  0.5  per  cent,  lysol  are  given  twice  a  day. 

In  hysteromyomectomy,  the  ovaries,  if  normal  or  nearly  normal, 
for  reasons  given  in  Chapter  XXXIII.,  should  be  preserved. 

In  all  operations  for  hysteromyomectomy  the  ligatures  and  sutures 
should  be  of  sterilized  catgut,  Claudius'  iodized  gut  preferred.  See 
Chapter  11. 

Advantages  of  End-to-end  Approximation. 

1.  The  broad  ligaments,  in  the  anatomic  sense,  take  the  place  of 
the  excised  uterus  and  form  a  pouch  posteriorly  like  the  cul-de-sac  of 
Douglas,  and  anteriorly  a  depression  that  answers  to  the  uterovesical 
pouch,  thus  conforming  to  the  normal  anatomy. 

2.  The  broad  ligaments,  thus  united,  together  with  adjacent  struc- 
tures, hold  up  the  rectum,  bladder,  vagina,  and  other  parts  of  the  pelvic 
floor,  and  in  so  doing  prevent  the  descent  of  these  organs,  which  so 
commonly  results  from  hysterectomy  as  ordinarily  performed. 

3.  The  broad  ligaments  and  adjacent  structures,  in  occupying  the 
space  left  by  complete  hysterectomy,  prevent  the  intimate  union  of 
the  rectum  and  bladder,  a  union  which  would  leave  only  a  thin  wall 
between  them,  through  which  infection  might  pass  from  one  to  the 
other. 

4.  The  operation  is  performed  more  easily  and  quickly  by  this 
method  than  by  that  of  transverse  suturing  of  the  wounded  ligaments. 


TUMORS  OF  THE   UTERUS -MYOMA.  409 

5.  There  is  after  closure  much  less  intraperitoneal  traumatism  and 
consequently  less  danger  of  sepsis,  adhesions,  and  secondary  hemor- 
rhage. 

Myomectomy  during  Pregnancy. 

The  following  conditions  more  or  less  strongly  contraindicate  sur- 
gical treatment  during  pregnancy  :  1.  Small  size  and  slow  growth  of 
the  tumor.  2.  Location  of  the  tumor  where  it  will  not  materially 
interfere  with  uterogestation  or  obstruct  delivery.  3.  Probability  that 
it  will  rise  spontaneously,  or  that  it  may  be  forced  manually  out  of  the 
pelvis  into  the  abdomen,  where  it  will  not  interfere  with  pregnancy 
or  parturition.  The  opposite  of  these  conditions  may  call  for  surgical 
measures.     The  following  radical  measures  should  be  considered  : 

1.  If  the  foetus  is  not  viable,  abortion,  and,  later,  myomectomy  or 
hysterectomy. 

2.  If  the  child  is  viable,  Csesarean  section  or  the  removal  of  the 
uterus  entire  or  supravaginal  hysterectomy — i.  e.,  Porro's  operation. 

3.  Removal  of  the  tumor  without  interrupting  pregnancy  or  sacri- 
ficing the  uterus. 

If  surgical  interference  is  inevitable,  and  gestation  has  not  ad- 
vanced beyond  the  end  of  the  third  month,  the  indication  is  for  abor- 
tion. Interruption  of  gestation  at  this  time,  and  a  radical  operation 
for  the  removal  of  the  tumor  later,  would  be  the  safest  course.  After 
the  third  month  the  danger  of  induced  abortion  is  increased  enor- 
mously. This  increase  comes  from  the  difficulty  of  delivering  the 
placenta,  from  infection,  and  from  hemorrhage.  Csesarean  section, 
to  be  followed  immediately  by  complete  hysterectomy  or  supravaginal 
hysterectomy,  may  now,  in  the  interest  of  the  child,  be  deferred,  if 
possible,  to  the  period  of  viability — that  is,  to  the  end  of  the  seventh 
month  or  later.  Removal  of  the  tumor  without  sacrificing  the  uterus 
or  interrupting  gestation  may  be  preferred  when  the  tumor  is  subperi- 
toneal and  removable  with  small  uterine  traumatism.  This  operation 
is  indicated  specially  in  subperitoneal  pedunculated  tumors. 

An  infected  myoma,  especially  if  complicated  wdth  pregnancy, 
demands  immediate  radical  measures,  and  if  the  uterus  also  is  in- 
fected may  call  for  not  only  myomectomy,  but  for  hysterectomy  as 
well.     See  Plate  VIII. 

Prognosis  after  Operation  for  Myoma  Uteri. 

The  danger  in  the  removal  of  a  uterine  myoma  varies  with  the 
skill  of  the  operator,  the  location  and  relations  of  the  tumor,  and  the 
condition  of  the  patient.  The  mortality  of  the  abdominal  operation 
in  the  hands  of  the  average  operator  has  been  placed  at  about  15  per 
cent.  This  is  too  high.  Under  favorable  conditions,  including  an 
expert  surgeon,  a  mortality  of  5  per  cent,  is  too  high.  Statistics 
usually  show  a  mortality  of  about  25  per  cent,  in  the  removal  of 
intraligamentous  tumors  with  broad  uterine  connections  and  of  supra- 
vaginal tumors  of  the  upper  part  of  the  cervix.  This,  again,  is  too 
35 


410  TUMORS,    TUBAL  PREGNANCY,  MALFORMATIONS. 

high.  The  method  already  described  for  the  removal  of  these  tumors 
by  myomectomy  with  gauze  drainage  into  the  vagina,  when  required, 
closure  of  the  tumor-cavity  in  the  abdomen,  and,  if  necessary,  liga- 
ture of  the  uterine  vessels,  has  reduced  the  mortality  to  a  very  small 
percentage.  Vaginal  extirpation  of  the  small  myomatous  uterus 
shows  a  mortality  of  less  than  3  per  cent.  Removal  of  a  tumor 
from  the  infravaginal  portion  of  the  cervix  and  removal  of  intra- 
uterine tumors  through  the  vagina  are  practically  without  danger. 
The  long-continued  menorrhagia  associated  so  commonly  with  uterine 
myomata  may  so  exhaust  the  woman  as  greatly  to  decrease  her  resist- 
ance, and  thereby  to  increase  the  danger  of  an  operation ;  hence  the 
occasional  necessity  of  preparatory  curettage,  uterine  tamponade, 
general  treatment,  and  delay  in  some  cases  for  weeks  or  months, 
until  the  systemic  condition  is  favorable.  Before  an  abdominal  opera- 
tion it  may  be  necessary  to  increase  the  haemoglobin  and  the  red 
blood-corpuscles  by  preparatory  treatment ;  the  haemoglobin,  if  possi- 
ble, should  be  brought  up  to  at  least  50  and  the  red  blood  count  to 
not  less  than  3,000,000. 

The  mortality  of  hysteromyomectomy  with  end-to-end  approxima- 
tion of  the  broad  ligaments,  as  described  above,  has  not  risen  above 
1  per  cent,  in  my  own  cases  during  the  last  six  years. 


CHAPTER    XXVIII. 

TUMORS  OF  THE  UTERUS  (Continued). 
CARCINOMA  AND  ENDOTHELIOMA. 

Pathology  of  Carcinoma  Uteri. 

Carcinoma  may  arise  from  any  portion  of  the  uterine  mucosa — 
L  €.,  from  the  cylindrical  epithelium  of  the  corporeal  or  cervical 
glands,  from  the  surface  cylindrical  epithelium  of  the  interior  of  the 
uterus,  or  from  the  pavement  epithelium  outside  of  the  external  os. 
The  variety  of ^  the  cancer  usually  corresponds  to  the  type  of  epithe- 
lium from  which  it  springs.  Cylindrical  cell  carcinoma  occurs  on 
the  corporeal  and  intracervical  mucosa,  and  the  pavement-cell  variety 
occurs  on  the  lower  portion  of  the  cervical  canal  or  on  the  external 
vaginal  surface  of  the  cervix.  This  rule  is  not  invariable.  E version 
of  the  intracervical  mucosa  is  quite  common — see  Laceration  of  the 
Cervix — hence  the  frequent  formation  of  the  cylindrical  cell  carci- 
noma outside  of  the  apparent  os  externum. 

From  the  ])athological  standpoint  there  are  thus  two  varieties  of 
carcinoma.  One  type  is  that  in  which  the  squamous  cells  of  the 
cervix  have  multiplied  in  an  atypical  manner  and  have  invaded  the 
deeper  tissues  ;  this  carcinoma  is  like  the  epithelioma  which  occurs  at 
the  junction  of  the  skin  and  mucosa  of  the  lip.  The  other  type  is 
that  in  which  the  cylindrical  cell  gland-acini  of  the  interior  of  the 
cervix  or  corpus  uteri  multiply  in  an  atypical  manner,  invade  the 
interglandular  stroma,  and  thus  conform  to  the  carcinomatous  type. 
The  two  varieties  of  carcinoma  are  therefore  called  : 

1.  Cylindrical  cell  carcinoma,  adenocarcinoma,  gland  carcinoma. 

2.  Pavement-cell  carcinoma,  squamous  carcinoma,  epithelioma. 
Carcinoma  of  the  cervix  usually  originates  near  the  os  externum, 

wherethe  cylindrical  and  pavement  epithelium  meet,  and  is  there- 
fore either  a  cylindrical  cell  or  a  pavement-cell  carcinoma,  or  both. 
Early  in  the  disease  the  tendency  of  the  former  is  to  extend  to  the 
submucous  structures,  and  of  the  "latter  to  confine  itself  more  to  super- 
ficial areas. 

When  the  deeper  tissues  are  involved  in  carcinoma,  the  affected  por- 
tion IS  enlarged,  hard,  marble-like,  and  friable.  The  surface  is  smooth, 
glistening,  and  flattened,  or  may  be  nodular.  Either  variety  rapidly 
extends  and  ulcerates  early.  The  margin  of  the  ulcer  is  irregular, 
hard,  and  usually  raised.  The  base  is  irregular  and  bleeds  easily! 
The  ulcerative  process  may  destroy  the  cervix  slowlv  or  rapidly. 

Carcinoma  may  extend  from  the  cervix  xderi  : 

1.  To   the  vaginal  vault,  anteriorly  or  laterally,  less  often  poste- 

411 


412  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

riorly.     The  advancing  margin  of  the  growth  is  raised,  rounded,  and 
hard. 

2.  To  the  broad  ligaments,  giving  them  on  digital  touch  a  hard, 
board-like  feel. 

3.  To  the  vesicovaginal  septum,  less  often  to  the  rectum. 

4.  Rarely  to  the  uterine  appendages,  urethra,  or  pelvic  bones. 

5.  To  the  corpus  uteri — frequently. 

6.  To  the  iliac  glands — not  usually  until  the  disease  has  involved 
the  broad  ligaments  ;  this  delay  is  because  the  squamous  cancer-cells 
are  too  large  to  pass  easily  through  the  lymph-radicles  of  the  cervix, 
but  not  too  large  to  traverse  the  lymph-vessels  of  the  ligaments. 

7.  After  the  disease  has  passed  beyond  the  cervix  uteri  the  kid- 
neys and  ureters  usually  are  involved  in  nephritis,  hydronephrosis,  or 
pyelonephrosis.  Dilatation  of  the  ureters  is  the  common  result  of 
inflammatory  constrictions  near  the  invading  growth,  pressure  of  the 
growth  on  the  ureter,  or  extension  of  the  growth  to  the  ureter. 

8.  Metastatic  cancer  extending  from  the  cervix  uteri  direct  to 
distant  organs  is  not  common. 

Carcinoma  may  extend  from  the  corpus  uteri: 

1.  To  the  broad  ligaments  and  parametria,  and  thence  to  any 
adjacent  structures,  such  as  peritoneum,  omentum,  mesentery,  intes- 
tine. Fallopian  tubes,  and  ovaries ;  all  these  organs  being  involved, 
if  at  all,  in  the  later  stages ;  complicating  cancer  of  the  liver  and 
lungs  is  rare. 

2.  To  the  lumbar  glands,  common ;  to  the  inguinal  glands,  not 
common  ;  the  iliac  glands  are  less  liable  to  involvement  than  in 
cancer  of  the  cervix. 

3.  To  the  cervix  uteri. 


Etiology  of  Carcinoma  Uteri. 

The  causes  of  cancer  are  unknown ;  the  predisposing  or  favoring 
conditions  are  as  follows  : 

1.  Age — the  disease  occurs  most  frequently  between  forty  and 
fifty.     The  extreme  limitations  are  between  eight  and  seventy-six. 

2.  Heredity — an  apparent  predisposing  cause. 

3.  Social  state — more  frequent  among  the  poor  and  ignorant. 

4.  Race — relatively  rare  among  negroes. 

5.  Trauma  of  labor — laceration  of  the  cervix  a  possible  predis- 
posing cause. 

6.  Endometritis  and  endocervicitis  are  said  to  be  favoring  con- 
ditions. 

Symptoms  and  Course  of  Carcinoma  Uteri. 

There  are  no  incipient  symptoms,  nor  at  any  time  in  the  course 
of  cancer  are  the  symptoms  pathognomonic.  As  the  disease  progresses 
the  following  disorders  always  appear ; 

1.  Hemorrhage. 

2.  Uterine  discharges. 


TUMORS  OF  THE   UTERUS.  413 

3.  Pain,  especially  in  adenocarcinoma. 

4.  Visceral  disorders. 

5.  Cachexia. 

1.  Hemorrhage  is  usually  the  first  symptom,  and  is  the  result  of 
accidental  injury  to  the  cancer,  and  to  ulcerative  processes.  Unfor- 
tunately it  is  attributed  often  to  irregularities  of  the  menopause  or  to 
a  return  of  menstruation  after  the  menopause  ;  hence  the  fact  that 
the  bleeding  of  carcinoma  often  is  disregarded  until  the  disease  has 
progressed  beyond  the  hope  of  cure.  The  reappearance  of  hemor- 
rhage one,  two,  three,  or  more  years  after  the  menopause  is  strong 
presumptive  evidence  of  cancer,  and  demands  immediate  examination. 
The  loss  of  blood,  at  first  slight,  is  noticed  commonly  after  straining 
at  stool,  or  vigorous  exercise,  or  coitus.  With  the  progress  of  the 
disease  the  hemorrhage  increases ;  it  may  be  nearly  or  quite  constant, 
may  occur  at  irregular  intervals,  or  in  the  form  of  menorrhagia  at  the 
catamenia.  Usually  the  patient's  strength  is  exhausted  slowly  by  a 
persistent,  slow  seeping  away  of  the  watery  blood.  On  the  other 
hand,  profuse,  even  dangerous,  hemorrhages  are  possible. 

The  menstrual  history  bears  no  very  significant  relation  to  the 
development  of  carcinoma.  The  disease  in  many  cases  follows  the 
menopause. 

2.  Uterine  Discharge. — The  character  of  the  discharge  varies 
with  the  progress  of  the  disease  : 

a.  Early  ;  discharge  watery,  serous,  transparent,  inodorous. 

6.  Later ;  discharge  watery  and  fetid. 

c.  As  ulceration  increases  and  growth  becomes  friable,  the  dis- 
charge is  more  profuse,  bloody,  turbid,  sometimes  purulent,  and 
always  of  a  most  nauseating  odor.  This  latter  symptom  continues 
more  or  less  constant  to  the  end,  and  is  characteristic  of  malignancy. 
The  discharge  is  called  "  carcinomatous  ichor,"  or  "  cancer  juice." 
All  excessive  discharges,  especially  after  the  menopause,  should  be 
regarded  with  suspicion. 

3.  Pain  is  rarely  present  while  the  growth  is  confined  to  the 
vaginal  portion  of  the  cervix.  Involvement  of  the  corpus  uteri  and 
of  the  structures  around  the  uterus  may  give  rise  to  sharp,  lancinating 
})ains.  These  pains,  although  often  described  as  pathognomonic,  are 
by  no  means  constant  or  confined  to  cancer.  They  may  be  supple- 
mented by  the  pains  of  pelvic  peritonitis.  The  peritonitis  protects 
the  general  peritoneum  by  adhesions  which  form  in  front  of  the  invad- 
ing carcinoma.  The  pains  are  due  to  pressure  on  the  pelvic  nerves  or 
to  actual  involvement  of  those  nerves  in  the  carcinoma  ;  they  commonly 
are  referred  to  the  region  of  the  pelvis,  perineum,  or  thighs,  and 
usually  indicate  that  the  disease  is  past  operative  cure.  The  retention 
of  secretions  in  the  uterus  from  occlusion  of  the  cervical  canal  by  the 
invading  carcinoma  may  give  rise  to  hydrometra  or  pyometra,  and 
cause  spasmodic  expulsive  uterine  pains  like  labor-pains. 

4.  Visceral  Disorders  may  be  consequent  upon  pressure  or  inva- 
sion of  neighboring  organs.  The  bladder  becomes  irritable.  Vesical 
catarrh,  strangury,  painful  urination,  pyuria,  and  cystitis  may  follow. 
Vesicouterine  or  vesicovaginal  fistula  often  results  from  the  destruc- 


414  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

tive  ulcerative  processes.  Uretero-uterine  and  ureterovaginal,  recto- 
uterine and  rectovaginal  fistula  may  occur  in  the  same  way.  Nephritis, 
uraemia,  hydronephrosis,  and  atrophy  of  the  kidney  are  among  the 
usual  resultant  complications.  Constipation  is  explained  as  follows  : 
First,  the  patient,  through  fear  of  pain  and  bleeding,  voluntarily 
retains  the  feces ;  second,  the  feces  become  dry  and  hard  from  loss  of 
water  in  the  ichorous  discharges ;  third,  the  bowel  is  incapacitated  by 
the  disease  for  the  ready  expulsion  of  its  contents.  Diarrhoea  may  be 
caused  by  irritation  of  the  bowel  from  the  invasion  of  the  cancer. 
Alternating  constipation  and  diarrhoea  are  not  uncommon. 

5.  Cachexia  appears  not  very  late  in  the  course  of  the  disease, 
and  is  a  characteristic  symptom.  It  is  marked  by  emaciation,  a  yel- 
lowish pallor  of  the  skin,  profound  anemia,  and  great  depression  of 
both  mind  and  body.  It  is  caused  by  toxic  agents  elaborated  by  the 
malignant  tumors  through  their  perverted  metabolism  and  by  malnu- 
trition due  to  anorexia,  vomiting,  pain,  and  hemorrhage. 

Diagnosis  of  Carcinoma  Uteri. 

The  sooner  the  carcinomatous  uterus  is  removed,  the  less  the 
likelihood  of  recurrence ;  hence  the  earliest  possible  diagnosis  is 
imperative.  Absolute  diagnosis  must  depend  usually  upon  the  micro- 
scopical findings.     A  probable  diagnosis  may  often  be  made  by 

1.  The  clinical  history. 

2.  The  physical  signs. 

1.  The  Clinical  History,  as  indicated  in  the  foregoing  paragraphs, 
gives  strong  evidence,  though  not  proof  of  cancer. 

2.  The  Physical  Signs  are  demonstrated  by  conjoined  examina- 
tion and  inspection.  The  extremely  fetid  odor,  which  clings  to  the 
examining  finger  despite  much  washing  and  the  energetic  use  of  the 
nail-brush,  usually  may  be  avoided  by  the  free  use  of  glycerin  as  a 
lubricant.  Infiltrating  carcinoma  of  the  cervix  is  recognized  as  a 
thick,  usually  hard,  more  or  less  nodular,  friable  growth.  The  fria- 
bility and  bleeding  are  almost  pathognomonic.  The  ulcers,  if  present, 
have  an  irregular,  hard,  raised  margin,  and  uneven  base,  and  bleed 
freely  upon  slight  injury.  Through  the  speculum  the  surface  before 
ulceration  appears  even  or  nodular,  marble-like,  and  glistening.  After 
ulceration  the  surface  is  ragged  and  irregular,  and  may  show  large 
excavations  from  the  sloughing  of  carcinomatous  tissue.  The  entire 
cervix  may  be  destroyed  in  this  way.  The  papillomatous  superficial 
variety  appears  as  a  soft,  friable,  bleeding,  cauliflower-like  mass. 


Explanation  of  Plate  XV. 

A.  Carcinoma  of  the  corpus  uteri  complicated  with  small  multiple  myomata. 

B.  Carcinoma  of  the  corpus  uteri.  On  the  right  side  the  disease  has  extended  nearly 
through  the  uterine  wall ;  on  the  left  side  the  disease  is  confined  apparently  to  the 
mucosa,  and  in  gross  appearance  resembles  polypoid  endometritis. 

C.  Carcinoma  of  the  cervix  uteri,  the  cervix  nearly  destroyed. 

D.  Carcinoma  of  the  cervix  uteri,  the  cervix  wholly  destroyed. 


PLATE  XV 


PLATE  XVI 

FIGURE   1. 


■  /i^i  -n 


m 


FIGURE  3. 


TUMORS  OF  THE   UTERUS.  415 

Diagnosis  of  Carcinoma  of  the  Cervix  Uteri. 

Early  carcinoma  of  the  cervix  without  great  care  may  be  over- 
looked. The  cervical  wall  around  the  external  os  may  be  only  a 
little  thickened  on  the  affected  side.  The  indurated  tissue  may 
appear  almost  insignificant  in  amount.  Extreme  friability  and  per- 
sistent bleeding  on  slight  abrasion  will,  however,  be  strong  diagnostic 
factors.  Subjective  symptoms  may  even  be  absent.  Excision  of  a 
small  piece  for  microscopical  examination  is  now  imperative.  This 
should  be  wedge-shaped,  and  should  include  a  portion  of  the  sur- 
rounding healthy  tissue.  The  slight  wound  may  be  closed  by  one  or 
two  sutures.  Cervical  scrapings  are  usually  useless  for  examination. 
Cervical  carcinoma  has  been  shown  by  reliable  statistics  to  be  about 
sixteen  times  more  frequent  than  carcinoma  of  the  corpus  uteri. 


Diagnosis  of  Carcinoma  of  the  Corpus  Uteri. 

Carcinoma  of  the  corpus  uteri  is  in  the  beginning  often  impossible 
to  recognize.  It  is  apt  to  appear  between  the  ages  of  forty  and  fifty. 
There  is  increased  and  irregular  menstruation,  which  often  is  attributed 
wrongly  to  the  menopause.  The  presence  of  a  slight  watery  dis- 
charge, even  though  odorless,  is  highly  diagnostic.  If  the  discharge 
is  very  fetid,  the  evidence  is  much  stronger.  The  general  tone  of 
the  patient  may  be  almost  up  to  the  normal  standard.  Conjoined 
examination,  preferably  with  rubber  gloves,  shows  nothing  except 
perhaps  slight  enlargement  of  the  uterus.  Life  now  may  depend 
upon  speedy  diagnosis.  The  whole  question  centres  in  the  product  of 
curettage  and  the  microscopical  findings.  Should  no  microscopical 
evidence  of  cancer  be  found,  the  curettage  should  be  repeated  when- 
ever the  hemorrhage  reappears.  In  cancer  the  discharge  always 
recurs  promptly.  The  scrapings  are  usually  much  more  abundant 
than  in  benign  growths. 

Frequently  recurring  glandular  hyperplastic  endometritis  with  much 
cystic  development  after  repeated  curettage,  especially  if  associated  with 
free  hemorrhage  and  a  loatery  discharge,  should  give  rise  to  grave 
apprehension,  and  would  justify  removal  of  the  uterus  on  suspicion. 

Advanced  carcinoma  of  the  body  of  the  uterus  is  recognized  by 
the  symptoms  already  described  and  by  conjoined  examination.     The 

Explanation  of  Plate  XVI. 

Figure  1. — Mucous  membrane  of  the  cervix  uteri  in  section  taken  just  above  the 
external  os,  showing,  a,  the  branching  racemose  gland  at  a  dips  down  from  the  free 
mucous  surface  to  the  muscularis.     15  diameters. 

Figure  2. — A  magnified  reproduction  of  gland  a  in  Figure  1.  Observe  the  horny 
layer  at  b,  the  cuboidal  epithelium  at  c,  and  the  papillary  layer  at  d.     60  diameters. 

Figure  3. — Pavement-  or  squamous-cell  carcinoma.  A  hypothetical  pavement- 
cell  carcinoma  is  here  shown  as  it  would  appear  if  it  attacked  gland  a  in  Figure  2. 
The  two  deep  pockets  of  gland  a  are  normal,  but  the  remainder  of  the  gland  has  been 
invaded  by  squamous  epithelium,  of  which  the  nuclei  are  stained  deeply  and  packed 
closely  together.  The  surrounding  stroma  is  infiltrated  with  small  round  cells.  Inva- 
sion of  the  gland  in  this  manner  by  squamous  epithelium  establishes  the  diagnosis  of 
carcinoma.  Two  normal  blood-vessels  are  shown  in  the  lower  part  of  the  Figure. 
Diagrammatic.     60  diameters. 


416  TUMORS,    TUBAL  PREGNANCY,  MALFORMATIONS. 


uterus  is  enlarged — often  two  or  more  times  its  normal  size.  It  is 
hard,  nodular,  and,  in  the  later  stages,  more  or  less  fixed.  Early 
fixation  also  occurs  in  cervical  cancer.  The  causes  of  fixation  are 
similar  to  those  which  produce  the  same  condition  in  pelvic  inflam- 
mation— i.  e.,  extension  of  the  disease  to  the  parametria.  The  lower 
extremities  become  cedematous  from  hydreemia,  from  pressure,  and 
from  thrombosis  of  the  pelvic  veins.  The  absolute  diagnosis  may 
depend  upon  the  microscope.  The  recognition,  however,  of  advanced 
carcinoma,  whether  of  the  cervix  or  corpus,  even  without  the  micro- 
scope, is  usually  not  difficult.     "  He  who  runs  may  read." 

The  following  diagnostic  signs  will  distinguish  pavement-cell  car- 
cinoma from  cylindrical  cell  carcinoma  : 


Pavement-cell  carcinoma — 
epithelioma. 

1.  Originates  in    pavement-cell    epithelium 
and  follows  that  type. 

2.  Forms  solid  finger-like  or  branching  in- 
growths. 

3.  Epithelial  pearls  may  be  formed. 

4.  Solid  alveoli  formed. 

5.  Breaks  down  rapidly  and  bleeds  freely. 


Cylindrical-cell  carcinoma — 
adenocarcinoma. 

1.  Originates  in  cylindrical  cell  epithelium 
and  follows  that  type. 

2.  Forms  gland  prolongations. 

3.  Absent. 

4.  Glandular  structures  always  recognizable, 

5.  Breaks  down  more  slowly. 


Differential  Diagnosis  of  Carcinoma  Uteri. 

The  conditions  most  liable  to  be  mistaken  for  carcinoma  are  : 


1.  Myoma. 

2.  Sarcoma. 

3.  Retained  placental  tissue. 

4.  Incomplete  abortion. 

5.  Hypertrophy  of  the  cervix. 

6.  Endocervicitis.     Nabothian 

follicles. 

The  diiferential  diagnosis  will  be  found  in  the  following  parallel 
columns  and  paragraphs  : 


7.  Endometritis. 

8.  Syphilis. 

9.  Chronic  metritis. 

10.  Ichthyosis. 

11.  Tuberculosis. 

12.  Laceration   of  the  cervix 

uteri. 


Advanced  carcinoma  of  the  corpus  uteri. 

1.  Cachexia,  hemorrhage,  and  very  foul  dis- 
charges. 

2.  Sloughing  tissues  very  friable. 

3.  Cervix  may  be  involved  by  extension. 

4.  Characteristic     epithelial     proliferations 
seen  by  microscope. 

Carcinoma  uteri. 

1.  Frequent. 

2.  Diffuse. 

3.  Surface  not  smooth. 

4.  Trabeculse  seen  on  cross-section. 

5.  Gland  formation,  abundant  stroma,  blood- 
vessels with  walls  in  stroma. 


Carcinoma  of  the  corpus  uteri. 

1.  History  of  pregnancy  commonly  absent. 

2.  Hemorrhage  from  uterus. 

3.  Quantity  of  tissue  removed  by  curette  may 
be  large. 

4.  Scrapings     composed    of    short,    friable 
threads  having  a  shaggy  appearance. 

5.  Microscopical  examination    shows  carci- 
noma. 


Sloughing  submucous  myoma. 

1.  Anaemia  from  hemorrhage ;  discharges  less 
foul. 

2.  Tough,  not  friable. 

3.  Cervix  not  so  involved. 

4.  Absent. 


Sarcoma  uteri. 

1.  Very  rare. 

2.  Rather  sharply  defined. 

3.  Previous  to  necrosis  surface  usually 
smooth. 

4.  Cross-section  shows  smooth,  homogeneous 
surface. 

5.  Cells  round  or  spindle-shaped,  little  or  no 
stroma;  in  place  of  blood-vessels  with  walls 
there  are  blood-spaces  in  direct  relation  with 
surrounding  cells. 

Retained  placental  tissue. 

1.  History  of  recent  pregnancy. 

2.  Same. 

3.  Quantity  always  large. 

4.  Scrapings  composed  of  myriads  of  long, 
slender  threads  having  shaggy  appearance. 

5.  Microscopical  examination  shows  products 
of  conception. 


PLATE  XVII 


w 


"vSx,^ 


t^. 


g 


p^^^^^ ' 


^yi^^ 


ro  «^ 


■i\. 


Adenocarcinoma  of  the  Corpus  Uteri. 

In  the  lower  middle  part  of  the  drawing  is  a  longitudinal  section  of  a  normal 
gland.  In  the  four  corners  are  glands  marked  a'  a"  a'"  which  have  many  layers 
of  epithelium  still  confined  within  the  glands.  Occupying  the  centre  of  the  draw- 
ing is  an  enormously  large  gland  the  right  half  of  which  (g)  is  nearly  normal,  but 
the  left  half  shows  three  branches  {h  b  b)  in  which  there  is  very  great  prolifera- 
tion of  epithelium  filling  that  part  of  the  gland  cavity  and  invading  the  stroma 
between  the  branches.  The  great  proliferation  of  cells  at  b  b  b  and  the  invasion 
gland  structure  into  the  stroma  establish  the  diagnosis  of  carcinoma.  The  char- 
acteristic small  round-cell  infiltration  around  the  carcinomatous  area  is  present. 
150  diameters. 


TUMORS  OF  THE    UTERUS. 


417 


Carcinoma  of  the  corpus  uteri. 

1.  No  history  of  pregnancy. 

2.  Scrapings  on  microscopical  examination 
show  carcinoma. 

3.  Cachexia. 

Carcinoma  of  the  cervix  uteri. 

1.  Cervix    enlarged,    friable,    breaks    down 
rapidly  and  bleeds  freely  to  touch. 

2.  Characteristic  offensive  watery  discharge 
—"cancer  juice." 

3.  Microscopical  examination  of  excised  por- 
tion shows  carcinoma. 


Incomplete  abortion. 

1.  History  of  pregnancy  and  abortion. 

2.  Scrapings  on  microscopical  examination 
show  products  of  conception. 

3.  Anaemia. 


Hypertrophy  of  the  cervix  uteri. 

1.  Cervix    enlarged,   tough,    and    does 
bleed  freely  to  touch. 

2.  Absent. 


not 


3.  Shows  cervical  structures  modified  only 
by  hypertrophy. 

Endometritis. — The  microscopical  cliiferential  diagnosis  has  been 
set  forth  in  the  chapter  on  Endometritis.  See  clinical  diagnosis  of 
the  two  diseases,  as  presented  in  the  same  chapter.  Polypoid  endo- 
metritis is  distinguished  from  carcinoma  of  the  corpus  uteri  by  the 
following  characteristics  : 

1.  Polypoid  eminences  not  sharply  defined. 

2.  Friability  not  marked. 

3.  Underlying  muscularis  not  invaded. 

Endocervicitis. — Cystic  and  polypoid  glandular  enlargements  due 
to  endocervicitis  have  certain  characteristics  which  might  lead  one  to 
mistake  them  for  cancer. 

Cystic  glandular  enlargement  (cystic  degeneration)  of  the  JSTaboth- 
ian  follicles  may  be  distinguished  from  cancer  by  the  following  char- 
acteristics : 

1.  The  large,  hard  nodular  cervix  is  smooth,  non-friable,  and  has 
no  tendency  to  bleed. 

2.  Puncture  of  cysts  reveals  mucous  contents. 

3.  Progress  of  disease  very  slow. 

4.  Microscopical  section  shows  cysts  lined  with  a  single  layer  of 
epithelium,  with  tunica  propria  unbroken  and  surrounded  by  normal 
stroma. 

5.  Condition  generally  due  to  laceration  of  cervix  and  e version  of 
the  cervical  mucosa. 

Polypoid  glandular  enlargement  (mucous  polypi)  differs  from  car- 
cinoma in  the  following  particulars  : 

1.  Springs  from  area  within  cervical  canal. 

2.  Lips  of  cervix  intact. 

3.  Polypi  rather  firm,  not  friable,  and  bleed  but  little. 

4.  Microscopical  section  shows  single  layer  of  epithelium  and 
normal  or  hypertrophied  cervical  glands. 

Syphilis  will  be  known  by  the  clinical  history.  In  doubtful  cases 
specific  treatment  should  establish  the  diagnosis. 

Chronic  Metritis. — Chronic  metritis  shows  a  history  of  inflamma- 
tion, is  associated  usually  with  endometritis,  does  not  cause  the  car- 
cinomatous cachexia  nor  the  offensive  watery  discharge.  On  conjoined 
examination  the  uterus  is  symmetrical,  while  a  carcinomatous  uterus 
is  often  nodular. 

Ichthyosis  Uteri. — This  condition,  first  described  by  Zeller/  1884, 

•  Zeller.  Plattenepithel  ira  Uterus  (ichthyosis  uterina).  Zeitschrift  fiir  Geburtshiilfe  und 
Gynaknlogie,  Band  xi.  Ries.  "  Eine  neue  Operationsmethode  des  Uteruscarcinoma,"  Zeitschrift 
fiir  Geburtshiilfe  und  Gyntikologie,  Band  xxi\r.  "  Ichthyosis,"  American  Gynecological  and  Ob- 
stetrical Journal,  February,  1886. 


418  TUMORS,    TUBAL  PREGNANCY,    MALFORMATIONS. 

is  marked  by  the  presence  of  two  or  more  layers  of  stratified  epithe- 
lium ;  in  the  cavity  of  the  uterus  it  has  been  observed  in  connection 
with  inversion  of  the  uterus,  with  cervical  polypi,  and,  according  to 
Zeller,  with  chronic  endometritis.  Transition  of  columnar  to  pave- 
ment-cell epithelium  occurs  in  hydrometra  and  hsematometra,  and  in 
extra-uterine  pregnancy ;  the  transformation  may  occur  where,  from 
any  cause,  the  mucosa  is  stretched  and  flattened,  so  as  to  stratify  the 
epithelium.  The  condition  gives  rise  to  no  unusual  symptoms  except 
such  as  ordinarily  would  be  observed  in  endometritis  or  in  the  begin- 
ning of  carcinoma  of  the  corpus  uteri.  The  scrapings  of  stratified 
epithelium  under  the  microscope  may  have  a  similar  appearance  in 
ichthyosis  uteri  and  carcinoma  uteri.  If  the  microscopical  findings 
show  that  the  stratified  epithelium  is  limited  to  the  superficial  struc- 
tures, the  case  is  one  of  ichthyosis  uteri.  If  the  epithelium  penetrates 
the  underlying  connective  tissue,  or  muscular  layer,  and  if  that  epi- 
thelium is  surrounded  by  round-cell  infiltration,  the  disease  is  prob- 
ably carcinoma.  Just  as  glandular  hypertrophy  may  be  the  starting- 
point  of  carcinoma,  so  may  ichthyosis. 

Tuberculosis  of  the  Uterus. — Tubercular  disease  in  the  uterus 
varies  according  to  the  location. 

Tuberculosis  of  the  endometrium  is  distinguished  from  carcinoma 
by  the  following  characteristics  : 

1.  Mucosa  at  first  smooth,  yellowish  white,  and  glistening;  later, 
yellowish-white  nodules  appear  on  surface  and  below  surface  of  endo- 
metrium. 

2.  Finally,  nodules  undergo  caseous  degeneration  and  ulceration. 

3.  At  times  small  yellowish  tubercles  surround  ulcers. 

4.  Disease  may  involve  entire  endometrium  and  may  extend 
through  the  muscularis  to  the  perimetrium. 

5.  Hemorrhage  not  characteristic. 

Tuberculosis  of  the  cervix  presents  the  characteristic  ulcerative 
processes  of  lupus. 

1.  Margins  of  ulcers  are  well  defined,  or  may  be  undermined,  and 
are  surrounded  by  tubercles. 

2.  Base  of  ulcers  is  studded  with  tubercles  and  covered  with  pus, 
necrotic  tissue,  or  caseous  matter. 

3.  Microscopical  section  shows  giant  cells  and  tubercular  bacilli. 
Tuberculosis  differs  from  carcinoma  in  all  the  above  particulars. 
Laceration  of  the  Cervix  Uteri. — This  condition  is  characterized 

by  inflammatory  and  mechanical  results  which  may  resemble  closely 
carcinoma  of  the  cervix.     They  are  : 

1.  E version  of  the  intracervical  mucosa  and  cystic  degeneration  of 
the  Nabothian  follicles  (see  Endocervicitis,  in  one  of  the  foregoing 
paragraphs. 

2.  The  everted  eroded  surfaces  present  an  irregular  and  sharply 
defined  line  of  demarcation. 

3.  Approximation  of  the  lacerated  margins  by  means  of  tenacula 
causes  the  everted  mucosa  to  be  rolled  in  and  to  disappear. 

4.  The  cervix,  if  indurated,  presents  the  peculiar  hardness  of 
hypertrophy ;  not  the  friability  of  carcinomatous  infiltration. 


TUMORS  OF  THE   UTERUS.  419 

5.  Ill  all  the  above  particulars  this  condition  differs  from  cancer. 
In  doubtful  cases  microscopical  examination  is  essential. 

The  differential  diagnosis  of  carcinoma  of  the  body  of  the  uterus 
may  be  rendered  difficult  by  such  associated  lesions  as  myoma,  sar- 
coma, endometritis,  salpingitis,  and  ovaritis. 

Causes  of  Death  from  Carcinoma  Uteri. 

The  causes  of  death  are  : 

1.  Exhaustion. 

2.  Sepsis. 

3.  Hemorrhage. 

4.  Uraemia. 

5.  Intercurrent  diseases,  such  as  peritonitis  and  pneumonia. 
Hemorrhage,  although  it  may  exhaust  the  vitality  slo^^'ly,  is  rarely 

a  direct  cause  of  death.  Fatal  peritonitis  seldom  occurs  from  exten- 
sion of  the  disease.  In  the  vast  majority  of  cases  death  is  from  mar- 
asmus or  uraemia,  or  both.  Fatal  septic  pneumonia  and  pulmonary 
oedema  may  be  caused  by  embolism. 

Prognosis  of  Carcinoma  Uteri. 

The  sole  hope  of  radical  cure  is  in  surgical  removal  of  the  carcinoma. 
Drugs  are  useless.  If  the  growth  has  progressed  beyond  the  limits  of 
a  radical  operation,  ^'All  hope  abandon  ye  toho  enter  here."  The  disease 
sometimes  will  destroy  life  in  a  few  months  or  weeks ;  it  may  for  a 
time  become  apparently  inactive,  or  develop  very  slowly,  and  then  go 
on  to  a  rapid  termination.  The  prognosis  as  to  limit  of  life  should  be 
guarded.  A  general  statement  that  death  is  more  liable  to  occur 
within  one  year  than  after  two  years  usually  will  be  safe. 

Diagnosis  of  Recurrence  of  Cancer  after  Removal. 

After  hysterectomy,  recurrence  may  be  suspected  under  the  follow- 
ing conditions : 

a.  Pain  radiating  to  hip  and  thigh. 

b.  CEdenia  in  lower  extremities. 

c.  Cachexia  and  failing  health. 

Diagnosis  of  Extension  of  Carcinoma  Uteri. 

Carcinoma  of  the  uterus  may  extend  to  adjacent  and  other  organs, 
as  follows : 

1.  Extension  to  the  Vagina,  recognized  by  : 

a.  Cartilage-like  hardness  and  nodules  in   the   vaginal  vault, 

due  to  carcinomatous  infiltration. 

b.  Ulcers  in  vaginal  vault  having   hard  border  and  bleeding 

base. 

2.  Extension  to  the  Rectum,  recognized  by  : 

a.  Bloody,  offensive  discharge  from  rectum. 
6.  Rectal  touch  shows  irregular  hard  post-uterine  mass  ex- 
tendinof  into  rectal  wall. 


420  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

c.  Rectal  mucosa  fixed  to  mass  and  ulcerated ;  borders  of 
ulcerated  surfaces  hard  and  raised. 

3.  Extension  to  Bladder,  recognized  by  : 

a.  Cystoscopy,  conjoined  examination,  digital  touch  through 

artificial  vesicovaginal  fistula. 

b.  Digital  palpation  of  bladder  through  urethra ;  not  advised. 

c.  Hsematuria. 

4.  Extension  to  Parametria,  recognized  by  the  following  conditions  : 

a.  Cancerous  infiltrate  is  harder  than  inflammatory  infiltrate. 
The  inflammatory  infiltrate,  unlike  that  of  carcincoma, 
first  forces  the  uterus  to  the  opposite  side,  and  later, 
as  the  mass  disappears,  contracting  structures  draw  it 
toward  the  affected  side.  Fixation  of  the  uterus  is  not 
a  reliable  sign,  because  the  uterus  may  also  be  fixed 
by  inflammatory  infiltrate. 

6.  Carcinoma  of  the  supravaginal  portion  of  the  cervix  gives 
rise  to  early  infiltration  of  the  parametria ;  carcinoma 
of  the  infravaginal  portion  gives  rise  later,  and  carci- 
noma of  the  corpus  still  later. 

c.  Hard  mass  extends  first  from  posterior  wall  of  the  cervix 
to  the  back  of  the  pelvis,  later  to  the  sides ;  best  pal- 
pated through  the  rectum. 

5.  Extension  to  the  Glands : 

a.  The  iliac  glands  are  the  first  to  be  involved  in  cancer  of 
the  cervix,  and  are  palpated  best  under  narcosis  per 
rectum,  in  front  of  the  sacro-iliac  joint ;  infiltration  of 
the  parametrium  precedes  infiltration  of  the  glands. 

6.  The  lumbar  glands  involved  in  cancer  of  the  corpus  uteri 
are  palpated  only  under  anaesthesia  through  the  abdom- 
inal walls  when  the  walls  are  thin  and  relaxed. 

6.  Extension  by  Metastasis  to  other  organs  is  a  late  manifestation, 

of  which  an  early  positive  diagnosis  is  impossible. 

Treatment  of  Carcinoma  Uteri. 

The  treatment  is  radical  when  the  cancer  has  not  extended  beyond 
the  limits  of  entire  removal ;  palliative,  when  it  cannot  be  removed 
entirely.  The  radical  treatment  should  always  be  complete  hysterect- 
omy. The  old  practice  of  high  amputation  of  the  cervix  for  cervical 
cancer  should  never  be  resorted  to,  for  one  can  never  be  certain  that 
the  disease  is  not  also  present  and  unrecognized  in  the  corpus  uteri. 

Indications  for  Hysterectomy. 
Hysterectomy  always  is  indicated  if  the  carcinoma  is  limited  to  the 
uterus;  such  limitation  may  be  possible  if: 

1.  The  uterus  is  normally  mobile  and  symmetrical. 

2.  The  uterus  is  not  excessively  enlarged. 

3.  The  iliac  and   lumbar  lymphatic  glands  are  not  enlarged ; 

this  is  difficult  to  determine. 

4.  The  vaginal  wall  is  not  involved  in  carcinoma. 

5.  The  parametria  are  not  infiltrated,  as  shown  by  vaginal  and 

rectal  examination. 


TUMORS  OF  THE   UTERUS.  421 

The  reverse  of  the  above  conditions  weakens  the  indication  for  hys- 
terectomy ;  the  stronger  the  reverse  the  weaker  the  indication. 

Enlargement  of  the  glands,  although  evidence  that  carcinoma  has 
extended  beyond  the  uterus,  does  not  necessarily  contraindicate  hyster- 
ectomy, although  it  renders  the  prognosis  less  favorable.  Such  enlarge- 
ment may  be  due  to  inflammatory  infection,  and  not  to  extension  of 
carcinoma.  Further  discussion  of  this  part  of  the  subject  follows 
under  Radical  Abdominal  Hysterectomy  in  this  chapter. 

Extension  of  cancer  to  the  vaginal  walls,  if  slight,  does  not  def- 
initely contraindicate  hysterectomy,  provided  the  diseased  portion  of 
the  vagina  can  be  removed  together  with  the  uterus.  Extensive  in- 
volvement of  the  vagina  and  fixation  of  the  uterus  in  surrounding 
cancer  contraindicate  the  operation. 

When  the  disease  has  passed  beyond  the  hope  of  radical  cure,  but 
not  beyond  the  limits  of  palliative  operation,  hysterectomy  is  per- 
formed sometimes  for  the  temporary  relief  of  symptoms  ;  the  benefits, 
however,  usually  are  not  sufficient  to  overbalance  the  dangers.  The 
removal  of  a  carcinomatous  cervix  alone  by  galvanocautery  as  a  rad- 
ical operation  is  usually  inadequate  ;  as  a  palliative  measure  in  advanced 
carcinoma  it  may  furnish  temporary  relief. 

HYSTERECTOMY. 

Hysterectomy  for  carcinoma  uteri,  whether  performed  by  vaginal 
or  abdominal  section  or  by  combined  vaginal  and  abdominal  section, 
should  be  complete ;  that  is,  it  should  completely  remove  at  least  the 
entire  uterus.  Up  to  the  present  time  the  most  common  operation 
has  been  ordinary  vaginal  hysterectomy — substantially  the  operation 
described  in  Chapter  XXIII.  on  Pelvic  Infection.  This  operation, 
although  having  almost  no  mortality,  per  se,  has  fallen  under  deserved 
criticism  because  of  the  discouraging  percentage  of  recurrences  at  the 
site  of  the  operation.  Consequently,  radical  efforts  have  been  made  to 
modify  it  in  such  a  way  as  to  increase  the  percentage  of  permanent 
cures.  Taking  the  operation  as  described  in  Chapter  XXIII.  as  a 
point  of  departure,  one  must  consider  how  much  further  it  is  practical 
to  go  in  the  removal  of  broad  ligaments  and  pelvic  and  lumbar 
glands,  how  far  traumatism  and  difficulty  of  technique  may  be  in- 
creased, to  what  extent  the  duration  of  the  operation  may  be  prolonged 
without  adding  enough  immediate  mortality  to  offset  any  possible 
advantage  accruing  from  increased  freedom  from  recurrence. 

In  estimating  the  merits  of  different  operations,  one  must  have  in 
mind  constantly  the  rule  which  applies  to  the  removal  of  cancer  in 
other  regions  ;  that  is,  complete  removal  of  all  apparently  diseased  tissue 
and  of  as  ivide  a  margin  of  adjacent  tissue  as  prudence  will  permit ; 
this  rule  is  based  upon  the  invariable  tendency  of  cancer  to  follow 
lymph-channels  into  surrounding  structures  and  to  involve  neighbor- 
ing lymphatic  glands.  The  above  considerations  lead  to  a  discussion 
of  the  following  subjects  : 

1.  Paravaginal  hysterectomy. 

2.  Radical  abdominal  hysterectomy. 

3.  Ignihysterectomy. 


422  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

1.  Paravaginal  Hysterectomy. 

Paravaginal  hysterectomy,  known  as  Schuchardt's  ^  operation,  is 
especially  adapted  to  cervical  carcinoma,  is  the  most  radical  of  all 
vaginal  operations,  and  is  performed  as  follows  :  ^ 

With  the  forefinger  and  the  thumb  of  the  left  hand  the  operator 
seizes  the  posterior  portion  of  the  left  labium,  Avhile  an  assistant 
seizes  the  parts  in  the  middle  line  and  puts  them  on  the  stretch.  The 
operator  then  makes  an  incision  between  the  two  sets  of  fingers  and, 
so  far  as  possible,  divides  at  one  stroke  in  a  forward  direction  the  vag- 
inal wall  up  to  the  left  side  of  its  insertion  into  the  cervix  uteri  and 
downward  and  backward  to  the  middle  of  the  coccygeal  region.  By 
this  incision  he  splits  the  whole  vaginal  tube,  the  left  labium,  the 
paravaginal  and  pararectal  tissues,  the  levator  ani  muscle,  the  coccy- 
geal muscles,  the  cellular  tissue  of  the  ischiorectal  fossa,  as  well  as  the 
skin  of  the  perineum  and  of  the  lateral  anal  region  down  to  the  sacrum. 
The  wound  in  the  pararectal  tissue  is  carried  to  the  left  only  far  enougli 
to  avoid  the  rectum  and  sphincter  ani  muscle — that  is,  about  a  finger's 
breadth  from  the  middle  line.  The  incision  on  the  left  side  is  more 
convenient  for  the  right-handed  operator,  but  when  a  portion  of  can- 
cerous rectum  must  be  removed  with  the  cancerous  vaginal  wall,  bilat- 
eral incisions  become  necessary. 

After  controlling  the  copious  venous  hemorrhage  the  surgeon  catches 
the  vagina  as  far  as  possible  away  from  the  cancer  with  vulsella,  and 
below  these  vulsella  makes  a  circular  incision  through  the  vagina,  con- 
necting at  right  angles  with  the  paravaginal  cut;  he  now  separates  the 
vagina  by  blunt  dissection  in  an  upward  direction  and  sews  the  cuff 
thus  formed  over  the  portio  vaginalis  in  order  to  protect  the  field  of 
operation  from  uterine  secretions,  the  sutures  being  left  long  to  serve 
as  guides  in  the  following  steps  of  the  operation. 

The  effect  of  this  paravaginal  incision  is  surprising.  In  place  of  a 
vaginal  tube  we  have  before  us  a  shallow  excavation  about  an  inch 
deep,  at  the  bottom  of  which  the  parametria  are  seen  in  full  extent 
and  within  easy  reach. 

The  operator  now  separates  the  bladder  in  front,  partly  by  scissors, 
partly  by  blunt  dissection,  clear  to  the  pelvic  cavity,  and  in  the  same 
manner  opens  into  Douglas'  space  behind ;  then  passing  the  left  fore- 
finger successively  behind  each  parametrium,  he  draws  it  within  easy 
reach  and  ligates  it,  together  with  its  broad  ligament,  as  far  from  the 
uterus  as  possible,  with  strong  catgut,  and  excises  the  uterus,  together 
with  the  adjacent  parametrium  on  each  side  of  it. 

In  the  removal  of  considerable  portions  of  the  parametria  the 
regions  of  the  ureters  are  invaded  and  the  ureters  themselves  may 
have  to  be  laid  bare.  Dissections  in  these  parts  involve  great  tech- 
nical difficulties,  and  should  be  undertaken  only  by  specially  expert 
surgeons.     In  this  connection  the  reader  is  referred  to  the  original 

1  The  reader  is  referred  to  a  masterly  paper  read  before  the  American  Gynecological  Society 
at  Niagara  Falls,  1905,  in  -which  George  Gellliorn ,  of  St.  Louis,  discussed  fully  the  various  radical 
operations  with  special  reference  to  paravaginal  hysterectomy. 

2  Adaptation  from  Gellhorn,  Trans.  Am.  Gyn.  Soc,  1905. 


TUMORS  OF  THE   UTERUS.  423 

literature,  especially  papers  by  Schuchardt/  Schauta/  Kroemer,' 
Kundrat/  Bovee/  and  Mackenrodt.® 

The  suggestion  of  Clark  to  make  the  operation  with  catheters  pre- 
viously passed  into  the  ureters  is  most  practical.  The  vaginal  portion 
of  the  wound  is  closed  loosely  by  catgut,  in  such  a  way  as  to  unite  the 
anterior  to  the  posterior  peritoneal  edges  and  to  draw  into  it  the  cut  ends 
of  the  broad  ligaments.  The  cutaneous  portion  is  closed  more  firmly, 
as  in  perineorrhaphy.  A  gauze  drain,  according  to  the  special  indica- 
tion, may  or  may  not  be  indicated.      Union  by  first  intention  is  usual. 

The  advantages  claimed  for  this  most  radical  of  all  vaginal  opera- 
tions are  less  immediate  danger  to  life,  in  comparison  with  radical 
abdominal  operations,  and  greater  freedom  from  recurrence,  in  com- 
parison with  the  ordinary  vaginal  operations.  The  relative  value  of 
Schuchardt's  operation  Avill  be  considered  later. 

2,  Radical  Alxiominal  Hysterectomy. 

The  development  of  this  operation  in  its  various  phases  is  insepa- 
rably connected  with  the  labors  of  H.  W.  Freund,  Rumpf,  von 
Eosthorn,  Ries,  Schauta,  Clark,  CuUen,  Werder,  Russell,  and  others. 

After  preliminary  curettage  and  cauterization  of  exposed  surfaces 
in  the  vagina  and  after  thorough  disinfection  of  the  vaginal  and  ab- 
dominal fields  of  incision,  the  ureters,  according  to  Clark,  should  be 
catheterized,  and  the  catheters  left  in  them  as  guides  by  which  the 
ureters  may  be  avoided  during  the  operation. 

The  patient  being  in  the  Trendelenburg  position,  thp  abdomen  is 
opened  between  the  symphysis  pubis  and  umbilicus  and  the  lumbar 
iliac  and  sacral  glands,  the  pelvic  ligaments,  and  the  parametria  are 
examined  for  more  accurate  diagnosis  of  the  disease.  Wertheim,  Ries, 
and  others  advocate  the  removal  of  glands  with  varying  degrees  of 
thoroughness  in  connection  with  the  radical  operation.  Others,  nota- 
bly Clark  and  Schauta,  take  the  reasonable  ground  that  in  very  many 
cases  the  glands  are  not  involved,  and  that  in  all  cases  the  removal  of 
them  so  far  increases  the  primary  danger  of  operation  as  to  outbalance 
any  possible  freedom  from  recurrence.  The  removal  of  glands  may 
be  disregarded,  and  for  purposes  of  this  description  it  is  so  decided. 

"  Special  stress,"  as  Clark  ^  wisely  says,  "  should  be  laid  upon  the 
necessity  of  this  preliminary  survey,  for,  as  the  question  must  now  be 
viewed,  it  is  useless  to  perform  more  than  a  simple  abdominal  opera- 
tion if  the  higher  groups  of  glands  are  involved,  for  in  such  cases  we 
can  only  hope  fi)r  a  palliative  effect  from  any  operation.     If,  on  the 

>  K.  Schuchardt.    Centralblatt  f.  Chirurgie,  1893,  No.  51. 
K.  Schuchardt.    Ueber  die  paravaginale  Methode  der  Extirpatio  uteri  und  ihre  Heilerfolge 
beim  Uteruskrebs.    Monatsschrift  f.  Geb.  u.  Gyn.,  1901,  xiii. 

K.  Schuchardt.    Transactiou  of  the  German  Gynecological  Congress,  1901. 

2  F.  Schauta.  Die  Operation  des  Gebaermutterkrebses  mittelst  des  Schuchardt'schen  Para- 
vaginalschnittes.    Monatsschrift  f  Geb.  u.  Gvn.,  1902,  xv. 

F.  Schauta.  Die  Berechtiguug  der  vaginalen  Totalexstirpation  bel  Gebaermutterkrebs. 
Monatsschrift  f.  Geb.  u.  Gyn.,  1904,  xix. 

3  P.  Kroemer.    Die  Lymphorgane  der  weib.  Genitalien,  etc.    Archiv  f.  Gyn.,  1904,  Ixxiii. 
^R.  Kundrat.    Ueber  die  Ausbreitung  des  Carciuoms  in  parametranen  Gewebe  bei  Krebs 

des  Colhim  Uteri.    Archiv  f.  Gvn.,  Ixix,  Heft  2. 

6  J.  W.  Bov6e.  The  Treatnient  of  Cancer  of  the  Cervix  Uteri  in  Advanced  Stages.  Amer- 
ican Medicine,  January  7,  1905. 

6  A.  Mackenrodt,    Zentralblatt  f.  Gyn.,  1905,  No.  11. 

'Kelly-Nobie,  volume  i,  p.  737. 


424  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

other  hand,  preliminary  examination  of  the  pelvic  structures  has  been 
negative  so  far  as  metastasis  or  wide  intraligamentary  extension  is 
concerned,  the  scope  of  the  local  operation  becomes  radical." 

The  operation  now  will  be  continued  as  follows  :  ^  The  intestines 
are  packed  well  back  into  the  abdominal  cavity  with  gauze  bolsters, 
wrung  out  of  hot  salt  solution.  Painstaking  care  in  this  step  renders  the 
operation  very  much  easier  and  guards  against  post-operative  complica- 
tions. The  fundus  is  grasped  by  a  heavy  tenaculum  forceps,  and  forcibly 
drawn  upward  to  the  opposite  side  from  that  upon  which  the  operation  is 
to  begin.  The  peritoneum  is  snipped  open,  as  suggested  by  Wertheim, 
beginning  over  the  bifurcation  of  the  common  iliac  artery  and  con- 
tinuing down  into  the  pelvis  to  the  point  where  the  ureters  enter  the 
bladder.  The  infundibulopelvic  ligaments  at  the  pelvic  brim  are  next 
ligated  doubly  and  cut  between  the  ligatures. 

The  round  ligament  is  separately  ligated  one  inch  from  the  cornu 
uteri  and  divided.  The  peritoneal  incision  is  now  carried  around  in 
front  of  the  uterus,  through  the  uterovesical  reflection  to  the  opposite 
side.  The  bladder  is  detached  from  the  uterus  with  sponge  pressure 
and  the  broad  ligaments  opened  by  the  same  means.  With  the  uterus 
sharply  drawn  upward  into  the  abdomen,  detachment  of  the  bladder 
from  the  cervix  is  completed,  and  the  dissection  carried  well  down 
into  the  paravaginal  tissues.  In  this  way  the  vagina  is  detached 
from  its  fixed  points  and  appears  as  an  isolated  sheath.  If  the  bougies 
are  in  place,  or  if  the  anatomic  guides  are  well  in  mind,  the  ure- 
ters can  most  easily  be  located  at  the  brim  of  the  pelvis  where  they 
cross  over  the  external  iliac  vessels.  From  this  point  they  are  traced 
downward  to  the  points  where  they  swing  inward  to  enter  the  bladder. 
With  the  ureters  isolated  and  pushed  out  of  the  way,  the  ligation  of 
the  uterine  vessels  becomes  a  relatively  safe  procedure.  The  vessels 
lifted  lip  on  the  tip  of  the  index-finger  are  doubly  ligated  well  out 
against  the  pelvic  wall.  The  ligature  is  best  applied  with  a  curved 
aneurysmal  ligature  carrier.  This  step  having  been  duplicated  on  the 
opposite  side,  the  chief  danger  of  hemorrhage  and  of  injury  to  the 
ureters  is  largely  overcome. 

The  broad  ligaments  are  now  cut  away  from  their  pelvic  attach- 
ments, leaving  the  uterus,  its  appendages,  and  the  upper  portion  of 
the  vagina  held  in  the  pelvis  by  the  uterosacral  ligaments.  The  uterus 
is  now  pulled  upward  and  forward  against  the  symphysis  pubis  to 
facilitate  the  division  of  the  recto-uterine  reflection  of  peritoneum  and 
the  uterosacral  ligaments.  The  peritoneum  should  be  opened  well 
back  of  the  cervix.  The  uterosacral  ligaments  are  ligated  or  clamped 
and  divided  as  close  to  their  sacral  attachments  as  possible.  Small 
bleeding  vessels  may  be  clamped  and  subsequently  ligated. 

Up  to  this  point  the  operation  has  followed  the  general  plan  of  all 
radical  operations,  but  here  the  best  suggestion  which  Wertheim  has 
offered  becomes  imperative.  Instead  of  using  imbricated  ligatures 
around  the  circumference  of  the  vagina,  Wertheim  has  employed  right- 
angled  clamps  with  which  to  compress  the  walls  of  the  vagina  from 
above  while  it  is  excised.     With   traction  forceps  the  uterus  is  pulled 

I  Adaptation  from  Clark.    Kelly-Noble,  volume  i,  pp.  738-744. 


TUMORS  OF  THE   UTERUS.  425 

as  high  as  possible  into  the  abdomen,  thus  bringing  a  considerable 
portion  of  the  vagina  .nto  view.  Two  clamps  are  applied  to  the  iso- 
lated vaginal  tube,  one  on  one  side  and  the  other  on  the  opposite  side 
and  overlapping  the  first.  These  clamps  are  quickly  placed  and 
permit  the  immediate  excision  of  the  uterus  with  the  upper  portion  of 
the  vagina.  In  the  separation  of  the  pelvic  attachments  of  the  uterus, 
and  in  cutting  through  the  vagina,  the  cautery  should  invariably  be 
employed,  and  after  the  excision  of  these  structures  the  surrounding 
tissues,  with  due  protection  to  the  ureter,  bladder,  and  rectum,  should 
be  thoroughly  burned.  This  igniextirpation  is  the  strongest  possible 
guard  against  recurrence.  While  he  believes  the  ligature  should  never 
be  discarded,  he  recognizes  without  reservation  the  splendid  value  of  the 
cautery  in  excising  cancerous  tissue.  By  the  cautery  method  adjacent 
tissue  which  might  escape  the  knife  is  removed.  Extirpation  being 
completed,  the  vagina  is  closed  below  the  clamps,  with  either  a  running 
or  an  interrupted  catgut  suture,  and  the  clamps  are  removed.  If  a 
gauze  drain  is  employed,  a  small  opening  is  left,  through  which  the 
gauze  projects  into  the  vagina,  from  which  it  can  be  removed  two  days 
later.  The  vesical  and  rectal  reflections  of  the  peritoneum  are  brought 
together  with  a  running  catgut  suture.  The  abdomen  is  closed  with- 
out drain  in  the  usual  manner. 

3.  Ignihysterectomy. 

It  is  highly  probable  that  the  great  difficulty,  tediousness,  and 
excessive  mortality  of  the  operation  just  described  will  so  far  outbal- 
ance any  possible  increase  of  permanent  cures  due  to  it  that  the  next 
generally  recognized  procedure  in  the  radical  surgery  of  uterine  can- 
cer will  to  a  greater  and  greater  extent  limit  the  use  of  hemorrhagic 
incisions  and  ligatures,  and  in  place  of  them  substitute  the  bloodless 
and  safer  method  of  igniextirpation.  The  foregoing  description  of 
technique  of  radical  abdominal  hysterectomy  includes  somewhat  exten- 
sive use  of  the  thermocautery  and  thereby  emphasizes  the  growing 
tendency  of  the  radical  operator  to  recognize  the  paramount  value  of 
this  agent. 

Igniextirpation  of  the  entire  uterus,  with  adjacent  tissues,  has  been 
perfected  by  X.  O.  Werder,^  of  Pittsburg.  The  technique  of  his 
operation,  substantially  as  set  forth  by  himself,  is  as  follows  : 

1.  Thorough  curettage  of  the  cancerous  surfaces  in  the  vagina  and 
control  of  resulting  hemorrhage  by  actual  cauterization. 

2.  An  incision  entirely  around  the  cervix  as  far  as  practicable  from 
the  affected  area  by  means  of  the  cautery  knife  at  a  dull  heat,  which 
prevents  oozing  and  renders  the  wound  dry.  This  incision  is  made 
while  the  uterus  is  drawn  well  down  toward  the  vulva,  and  the  vag- 
inal Avails  protected  from  the  hot  knife  by  means  of  retractors.  Dis- 
section by  the  cautery  knife  is  continued  anteriorly  between  the 
bladder  and  uterus,  the  bladder  being  drawn  firndy  away  from  the 
uterus  by  means  of  a  retractor  until  the  peritoneum  is  reached  but  not 
opened.  The  cul-de-sac  of  Douglas  is  then  entered  by  similar,  careful 
dissection,  guided   by  the  index-finger.     The   lateral    vaginal  attach- 

1  Werder,  X.  O.    Surgery,  Gynecology,  and  Obstetrics,  January,  1907. 
26 


426  TUMORS,   TUBAL  PBEGNAyCY,  MALFORMATIONS. 

meuts  are  tbeu  burued  through.  The  vagiDal  wound  is  carefully  in- 
spected now  and  all  surfaces  not  thoroughly  blackened  and  charred 
are  gone  over  agam  by  the  dome-shaped  cautery  until  thoroughly 
charred.     The  vagina  is  now  packed  lightly  with  gauze. 

3.  The  abdomen  having  been  prepared  for  laparotomy,  a  median 
incision  is  made  between  the  symphysis  and  umbilicus,  and  the  uterus 
seized  and  drawn  into  the  opening  by  means  of  vulsellum  forceps  and 
carefullv  packed  off  from  the  surrounding  peritoneal  cavity  by  means 
of  sponge  pads. 

4.  The  bladder  peritoneum  at  the  vesical  reflection  is  now  dissected 
off  from  side  to  side  by  means  of  the  hot  knife,  and  the  anterior  vag- 
inal pouch  is  opened  so  as  to  expose  the  vaginal  gauze  packing.  A 
Downs'  electro-thermic  cautery  clamp  is  then  applied  to  the  right 
infundibulopelvic  ligament  and  round  ligament,  the  surrounding  parts 
being  carefully  protected  by  the  shield  and  by  additional  pads.  The 
tissues  included  in  the  clamp  are  then  thoroughly  treated  by  the  gal- 
vanic heat  until  thev  appear  as  a  thin  Avhite,  horny  ribbon.  The  clamp 
is  then  removed  and  this  ribbon  is  cut  through  at  its  inner  margin, 
and  if  free  fi^m  bleeding  is  dropped.  The  other  side  is  treated  in  the 
same  way. 

5.  The  parametrium  is  seized  on  the  least  affected  side  with  the 
cautery  clamp  and  burned  through,  the  bladder  and  ureter  being  care- 
fully avoided.  The  horny  ribbon  thus  formed  is  cut  through  and 
the  remaining  portion  of  the  broad  ligament  and  uterosacral  ligament 
are  treated  in  the  same  manner  and  dropped.  One  side  of  the  uterus 
now  being  freed  from  all  its  attachments,  the  same  treatment  is  re- 
peated on  the  other  side.  If  the  technique  has  been  good,  the  cauter- 
ized surfaces  will  be  dry,  no  blood  except  from  the  preliminary 
cauterization  having  been  lost. 

6.  The  stump  of  the  vagina  now  exposed  is  closed  by  means  of  a 
running  catgut  suture,  the  bladder  is  brought  over  the  sutured  vaginal 
stump,  and  its  peritoneum  sutured  to  the  rectum.  Adjacent  peritoneum 
is  now  stitched  over  each  broad  ligament  stumj). 

7.  The  entire  field  of  operation  now  being  covered  and  protected 
against  infection  by  peritoneum,  and  having  no  exposed  surfaces,  the 
abdomen  is  closed  without  drain  in  the  usual  manner. 

History  and  Rationale  of  Igniextirpalion. — Werder  has  based  his 
operation  upon  the  principles  of  the  well-known  Byrne  operation  of 
amputation  of  the  cervix  by  the  galvanocautery,  extending  it  to  com- 
plete hysterectomy.  The  statistics  of  Byrne  ^  are  a  matter  of  history. 
They  show  369  cases  of  cervical  cancer  removed  by  galvanocautery, 
with  no  primar}^  mortality,  and  19  per  cent,  of  permanent  cures — a 
very  remarkable  result,  even  allowing  for  some  possible  errors  of  diag- 
nosis which  may  have  led  to  the  inclusion  of  a  few  cases  in  which  the 
presence  of  undeniable  cancer  remains  unproved. 

'•'Byrne  in  all  his  writings  on  this  subject  emphasizes  the  impor- 
tance of  thorough  and  repeated  cauterizations  of  the  wound  surfaces 
and  edges  from  which  cancerous  material  has  been  removed,  regarding 
it  as  the   best  safeguard  agaiiist  the  recurrence  of  the  disease."     He 

1  TxaiLsactions  of  the  American  Gynecological  Society,  Tolume  xiv,  1889.    Same,  188. 


TUMORS  OF  THE  UTERUS.  427 

thinks  that  "  there  is  harcUj  any  doubt  that  the  developmental  activity 
of  the  cancer  cells  and  germs,  in  certain  stages  and  imder  certain  con- 
ditions, may  be  arrested  or  permanently  destroyed  by  a  degree  of  heat 
much  below  that  which  would  be  detrimental  or  destructive  to  normal 
tissues "  ;  he  is  certain  that  "  the  thermal  agent  exerts  some  strong 
modifying  influence  on  pathologic  processes  much  deeper  than  the 
surface  actually  cauterized,  hence  the  importance  of  repeated  appli- 
cations, so  that  every  spot  suspected  of  contamination  may  be  thor- 
oughly charred." 

Byrne's  results,  especially  the  freedom  from  local  recurrences,  would 
seem  to  justify  the  above  conclusions.  The  most  remarkable  feature 
of  this  operation,  when  compared  to  other  operative  measures,  is  un- 
questionably the  absence  of  vaginal  recurrences.  Byrne  says  :  "  I  have 
never  known  an  instance  of  relapse  in  which  the  disease  has  returned 
to  the  part  from  which  it  had  originally  been  excised.  I  have  repeat- 
edly observed  the  reappearance  in  the  fundus,  ovaries,  and  some  of 
the  adjacent  tissues,  but  I  have  never  known  a  single  instance  in 
which  the  disease  has  reappeared  on  or  very  close  to  the  cauterized 
surface  from  Avhich  the  cervix  had  been  removed  by  galvanocautery." 
This  same  immunity  from  local  recurrence  is  claimed  by  other  opera- 
tors using  the  galvanocautery,  such  as  Pawlick,  Madden,  and  others, 
so  that  Byrne's  experience  seems  by  no  means  singular.  The  facts 
apparently  bear  out  Byrne's  assertion  that  the  influence  of  the  cautery 
extends  beyond  the  actual  field  of  operation,  carrying  destruction  to 
cancerous  elements  deep  into  the  tissues,  and,  therefore,  doing  much 
more  radical  work  than  can  be  accomplished  by  the  use  of  the  knife 
or  scissors  under  similar  conditions. 

Byrne's  experience  covers  367  cases,  extending  over  a  period  of 
twenty  years,  without  a  single  operative  death;  140  of  these  Avere 
carcinoma  of  the  cervix;  in  219  cases  both  cervix  and  body  were 
involved,  and  in  only  8  cases  was  the  disease  confined  to  the  corpus 
uteri;  151  cases  were  lost  sight  of  during  the  first  year;  there  re- 
mained, therefore,  21  6  cases  of  which  the  subsequent  history  is  known. 
Of  these,  19  remained  free  from  the  disease  from  ten  to  eighteen  years, 
22  for  five  years  or  more,  and  93  for  two  years  or  more.  Thus  19  per 
cent,  were  free  from  recurrence  for  five  years  or  more,  and  over  43 
per  cent,  for  two  years  and  over.^ 

Advantages  of  Ignihysterectomy. — The  advantages  of  this  operation 
are  numerous  and  convincing  ;  they  are  : 

a.  Comparative  simplicity  of  technique. 

6.  Comparative  freedom  from  post-operative  infection. 

c.  Comparative  freedom  from  hemorrhage  ;  most  important  in  view 
of  the  fact  that  cancerous  patients  are  anemic. 

d.  Surprisingly  low  percentage  of  immediate  mortality,  considering 
the  radical  nature  of  the  operation. 

e.  A  most  encouraging  percentage  of  permanent  cures,  especially 
when  due  allowance  has  been  made  for  the  much  greater  immediate 
mortality  of  paravaginal  hysterectomy  and  radical  abdominal  hyster- 
ectomy by  the  methods  of  Schuchardt,  Wertheim,  and  others. 

1  Quoted  from  Werder,    Kelly-Notile,  volume  i. 


428  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

Mortality  of  Hysterectomy  for  Carcinoma. — The  mortality 
depends  upon  the  character  of  the  operation.  Schuchardt's  operation 
will  show  a  mortality  of  at  least  10  per  cent.  The  radical  vaginal 
operation  in  the  hands  of  expert  operators  will  show  an  immediate 
mortality  of  from  10  to  20  per  cent.  The  mortality  with  improved 
technique  probably  cannot  be  reduced  below  10  per  cent.  The  ordi- 
nary vaginal  hysterectomy,  as  described  in  Chapter  XXIII.,  for  pelvic 
inflammation,  in  properly  selected  cases  shows  in  expert  hands  not 
over  1  per  cent,  of  immediate  mortality.  Ignihysterectomy  as  per- 
formed by  Werder  is  almost  as  safe. 

Recurrence  of  Carcinoma  after  Hysterectomy. — The  recur- 
rence of  cancer  after  hysterectomy  is  less  frequent  than  after  the  re- 
moval of  cancer  from  other  parts  of  the  body.  Even  in  cancer  of  the 
breast,  where  by  reason  of  the  exposed  position  of  the  growth  the 
diagnosis  usually  is  made  earlier  than  in  the  uterus,  recurrence  is  much 
more  frequent.  This  is  true  notwithstanding  the  common  practice  of 
thorough  attempt  at  removal  of  the  subclavian  and  axillary  glands  in 
connection  with  breast  operations,  and  notwithstanding  the  fact  that 
in  the  usual  hysterectomy  the  parametric  glands  seldom  are  removed. 
The  statistics  of  the  best  operators  show  freedom  from  the  disease  two 
or  more  years  after  vaginal  hysterectomy  by  the  ordinary  method,  as 
described  in  Chapter  XIII.,  in  an  appreciable  number  of  cases. 

The  percentage,  however,  of  permanent  cures  with  any  operation 
is  enormously  greater  for  corporeal  than  for  cervical  cancer — placed 
by  some  observers  as  high  as  75  per  cent,  for  the  former  and  as  low 
as  5  per  cent,  for  the  latter. 

Schuchardt's  operation,  which  if  thoroughly  performed  will,  per- 
haps, show  almost  as  high  an  immediate  mortality  as  the  radical  vagi- 
nal operation  without  removal  of  the  glands,  will  be  followed,  doubt- 
less, by  a  somewhat  larger  percentage  of  recurrences.  It  is  more 
than  possible  that  ignihysterectomy,  which  of  all  radical  operations 
has  immeasurably  the  least  primaiy  mortality,  will  give  almost  if 
not  quite  as  much  freedom  from  recurrence  as  can  be  accomplished  by 
either  of  the  other  radical  operations. 

The  Operation  of  Election. — In  our  present  unsatisfactory  state 
of  knowledge  we  may  summarize  as  follows  : 

1.  The  removal  of  glands  is  of  questionable  value  as  a  protection 
against  recurrence,  is  extra  hazardous,  and  involves  an  immediate 
mortality  which  more  than  offsets  any  probable  advantage.  The  diffi- 
culty and  danger  of  removal  of  all  the  lymphatic  glands  in  connection 
ivith  hysterectomy  will  be  apparent  from  examination  of  the  frontispiece ; 
moreover,  removal  of  the  lymph-vessels,  through  which  carcinoma 
must  travel  to  reach  the  glands,  is  impossible ;  therefore,  if  cancer  has 
passed  far  beyond  the  uterus,  removal  of  glands  is  of  doubtful  value. 

2.  If  the  parametria,  and  especially  the  glands,  are  demonstrably 
affected,  a  palliative  operation  only  should  be  elected.  See  Palliative 
Treatment. 

3.  If  the  parametria  and  glands  are  not  demonstrably  affected,  and, 
therefore,  a  radical  operation  gives  hope  of  permanent  cure,  the  choice 
will  be  between  radical  abdominal  operation  without  removal  of  glands, 


TUMORS  OF  THE   UTERUS.  429 

on  the  one  hand,  and  ignihysterectomy  on  the  other.  The  latter  pro- 
cedure, in  consideration  of  its  lesser  immediate  mortality,  and  its  en- 
couraging freedom  from  recurrence,  would  appear,  for  the  present  at 
least,  to  offer  the  maximum  advantages,  both  from  the  conservative 
and  from  the  radical  points  of  view.  Radical  abdominal  hysterectomy 
could  not  remove  the  parametria  and  broad  ligaments  much  more  than 
half  an  inch  nearer  to  the  pelvic  walls  than  ignihysterectomy.  This 
increased  removal  would  hardly  offset  the  additional  mortality  of  the 
former  operation.  Besides,  the  effect  of  the  cautery  may  be  destruc- 
tive to  cancer  far  beyond  the  charred  section. 

Early  diagnosis  must  be  urged  as  a  necessary  factor  in  the  successful 
surgical  treatment  of  cancer  of  the  uterus. 

PALLIATIVE  TREATMENT. 

Unfortunately,  the  onset  of  cancer  of  the  uterus  is  so  insidious 
that  early  symptoms — pain,  hemorrhage,  watery  discharge — are  over- 
looked or  attributed  to  other  causes ;  hence,  the  diagnosis  usually  is 
not  made  until  too  late  for  permanent  cure  by  radical  hysterectomy. 
In  later  stages,  when  the  cancer  has  extended  to  the  bladder  or  rectum, 
or  has  involved  demonstrably  the  vagina,  parametria,  or  glands,  and 
especially  when  the  uterus  is  fixed  in  carcinomatous  infiltrate,  with 
tliickening  of  the  broad  ligaments,  hysterectomy  is  permissible  only  as 
a  palliative  measure  and  is  of  questionable  value ;  under  these  condi- 
tions the  operation,  if  done  at  all,  should  be  simply  local  hysterectomy, 
as  set  forth  in  Chapter  XIII.  Other  palliative  treatment  which  does 
not  involve  the  removal  of  the  uterus  is  both  local  and  systemic. 

The  purpose  of  local  treatment  is  to  check  the  exhaustive  hemor- 
rhages and  discharge.  This  may  be  accomplished  by  sharp  curettage 
of  the  more  superficial,  soft,  ulcerating  portion  of  the  cancerous  growth. 
Remember  that  the  disease  in  advanced  cases  may  have  extended 
through  vesical,  rectal,  or  uterine  walls,  and  that  without  care  the 
bladder,  bowel,  or  peritoneum  may  be  opened.  The  redundant  can- 
cerous mass  having  been  removed  by  the  curette,  the  bleeding  surfaces, 
that  is,  the  exposed  surfaces,  should  be  charred  over  with  the  Paquelin 
or  galvanic  cautery. 

The  cancerous  growth  may  be  kept  down  and  the  fetid  discharges 
at  the  same  time  deodorized  by  the  application,  every  three  or  four 
days,  of  a  saturated  solution  of  iodine  crystals  in  pure  carbolic  acid. 
This  application  is  made  best  on  small  tampons.  The  healthy 
parts  of  the  vagina  may  be  protected  by  covering  the  mucosa  with 
gauze  pads  during  the  application  of  the  solution. 

Deodorizing  douches  are  useful  to  destroy  the  nauseating  fetor  of 
the  discharges.  Among  the  best  of  these  are  peroxide  of  hydrogen, 
a  2  per  cent,  solution  of  potassium  permanganate,  a  weak  solution 
of  formalin,  or  liquor  sodse  chlorinata  (one  part  to  ten  parts  of 
Avater). 

Hemorrhage  is  controlled  best  by  the  curette  and  cauterization, 
already  described,  but  a  sudden  profuse  hemorrhage  may  be  checked 
by  a  douche  of  hot  water,  hot  vinegar,  or  hot  alum  solution.     Should 


430  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

the  vaginal  tampon  be  used,  it  will  become  intolerably  offensive,  and 
therefore  should  be  removed  every  twenty-four  hours.  The  erosions 
and  excoriations  of  the  external  genitals  and  nates,  which  are  caused 
by  the  ichorous  discharges  from  above,  may  be  relieved  by  frequent 
bathing  and  by  the  application  of  benzoated  zinc  oxide  ointment. 

The  general  treatment  includes  regulation  of  the  bowels  and  kid- 
neys, tonics,  nutritious  food,  and  mild  exercise.  Pain  is  a  clear  indi- 
cation for  morphine  or  opium  in  quantity  sufficient  to  give  relief.  Life 
will  be  limited  to  a  few  months  ;  hence  the  danger  of  the  opium  habit 
is  not  significant.  Numerous  drugs,  both  for  local  and  systemic  use, 
have  been  lauded  as  cancer  cures  ;  they  are,  so  far  as  their  merits  have 
been  investigated,  useless. 

ENDOTHELIOMA  OF  THE  UTERUS. 

Pathology,  Diagnosis,  and  Treatment. 

Endothelioma  is  a  very  rare  malignant  new  formation  arising  from 
the  endothelium  of  blood-vessels,  or  of  lymph-vessels,  or  of  serous 
surfaces ;  it  closely  resembles  carcinoma  in  gross  appearance  and  clin- 
ical manifestations.  The  entire  lumen  of  the  vessel  is  distended  with 
proliferating  endothelium,  which  assumes  a  variety  of  shapes.  The 
cells  usually  form  nests  and  strands  similar  to  those  of  carcinoma.  The 
diagnostic  point  is  the  origin,  as  stated  above.  The  diagnosis  can 
be  made  only  by  microscopical  examination.  The  growth  is  found  in 
the  cervix  and  corpus  uteri,  and  very  rarely  also  in  the  ovary,  Fallo- 
pian tube,  and  vagina.  The  treatment  is  the  same  as  that  of  other 
malignant  disease. 


PLATE  XVIIl 


j.K.r. 


Sarcoma  of  the  Body  of  the  Uterus. 


CHAPTER   XXIX. 

TUMORS  OF  THE  UTERUS  (Continued). 

SARCOMA   OF   THE   UTERUS. 

Sarcoma  is  a  malignant  tumor  belonging  to  the  connective-tissue 
group,  and,  as  compared  with  carcinoma,  is  of  rare  occurrence ;  it  is 
more  apt  to  occur  during  the  period  of  sexual  maturity,  but  has  been 
ol)served  as  late  as  the  age  of  seventy.  Like  carcinoma,  it  is  more 
frequent  between  forty  and  sixty. 

Histogenesis  and  Etiology  of  Sarcoma. 

Sarcoma  may  develop  from  any  of  the  following  sources : 

1.  The  interglandular  connective  tissue  of  the  endometrium. 

2.  The  intermuscular  connective  tissue  of  the  myometrium. 

3.  The  walls  of  the  blood-vessels. 

4.  The  perivascular  connective  tissue. 

5.  The  muscle-cells.^ 

6.  Any  of  the  structures  of  a  uterine  myoma. 
The  causes  of  sarcoma  are  unknown. 

Classification  and  Pathological  Anatomy  of  Sarcoma. 

Sarcoma  may  be  divided  histologically  into : 

1.  Small  round-cell  sarcoma. 

2.  Large  round-cell  sarcoma. 

3.  Spindle-cell  sarcoma. 

Sarcoma  may  be  divided  regionally  into : 

1.  Sarcoma  of  the  uterine  mucosa. 

2.  Sarcoma  of  the  entire  uterus — diffuse  sarcoma. 

Sarcoma,  especially  when  it  has  developed  from  myoma,  may  have 
many  of  the  gross  characteristics  of  myoma — that  is,  it  may  be  sub- 
mucous, subserous,  intramural,  round,  oblong,  irregular,  multinodular, 
soft,  hard,  circumscribed,  or  diffuse.  The  older  pathologists  designated 
these  growths  as  "  recurring  fibr'oids '' ;  they  sometimes  are  called 
fibrosareomata  or  interstitial  sar^comata.  They  rarely  are  encapsu- 
lated, though  usually  well  defined.  The  cells  are  round  or  spindle, 
and  the  spindle  cells  predominating  are  often  so  elongated  as  to  ap- 
pear like  fibrous  tissue,  hence  the  name  fibrosarcoma. 

Diffuse  sarcoma  usually  develops  from  the  interglandular  connec- 
tive tissue  of  the  endometrium.  In  this  form  the  small  round  cell 
usually  predominates  over  the  spindle  cell.  The  growth  may  be  con- 
fined to  separate  areas,  or  may  infiltrate  the  whole  endometrium  and 
rapidly  involve  the  entire  uterus  and  adjacent  organs.  It  develops 
both  in  the  endometrium  and  in  the  muscularis.     Intra-uterine  sar- 

>  Whitridge  WiUiams.     American  Journal  of  Obstetrics,  1894,  vol.  xxix. 

431 


432  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

coma  may  take  the  form  of  numerous  soft  medullary  polypi.  When 
removed  by  the  curette,  they  have  the  gross  appearance  of  carcinomaj 
and  microscopically  the  small  round  cells  of  sarcoma  may  be  difficult 
to  distinguish  from  the  round  cells  of  inflammation  in  endometritis. 

There  is  a  form  of  sarcoma  which  in  gross  appearance  resembles 
grape-like  bodies,  and  sometimes  is  called  butyroides  ;  it  is  extremely 
rare,  usually  originates  in  the  cervix  uteri,  and  has  the  form  of  cyst- 
like masses  resembling  hydatid  moles.  The  growth  is  composed 
mostly  of  round  and  spindle  cells ;  it  has  been  observed  in  the  uteri 
of  adult  women  and  children,  and  in  the  vagina  of  children.^  The 
development  is  most  rapid  and  malignant. 

All  sarcomata,  especially  the  diffuse,  are  extremely  vascular.  The 
blood-vessels  sometimes  are  dilated  so  enormously  as  to  form  cavern- 
ous spaces.     The  lymph-spaces  may  dilate  into  cystic  cavities. 

Symptoms,  Course,  Diagnosis,   and   Prognosis   of  Sarcoma  of 

the  Uterus. 

The  symptoms  and  course  vary  with  different  forms  of  sarcoma. 

The  interstitial  spindle-cell  sarcoma,  formerly  called  recurring 
fibroid,  is  sometimes  of  slow  growth.  In  exceptional  cases  it  may  not 
destroy  life  for  several  years. 

The  diffuse,  small  round-cell  sarcoma,  on  the  contrary,  is  ordinarily 
much  more  malignant  than  carcinoma;  it  often  goes  on  to  a  fatal 
result  in  a  few  months.  The  small  round-cell  sarcoma  is  most  malig- 
nant, the  large  round-cell  less  malignant,  and  the  spindle-cell  least 
malignant. 

The  tendency  of  sarcoma  is  to  scatter  its  nodules  through  the 
uterine  walls,  to  penetrate  the  blood-vessels,  to  extend  to  the  peri- 
toneum, and  to  involve  adjacent  organs.  The  thickened,  enlarged 
uterus,  the  bladder,  and  the  neighboring  intestines  then  are  matted 
together  in  the  sarcomatous  disease  and  materially  increase  the  size  of 
the  tumor.  The  disease  is  prone  to  send  its  emboli  by  the  veins  to 
the  lungs,  liver,  kidney,  spleen,  and  brain.  These  and  other  organs 
now  may  become  rapidly  involved  in  metastatic  sarcoma.  It  is  a 
peculiarity  of  the  disease  that  emboli  pass  through  the  veins  to  dis- 
tant organs.  In  this  respect  it  differs  from  carcinoma,  which  is  apt  to 
travel  by  the  lymphatics  and  to  be  arrested  by  thrombic  plugging  at 
points  much  nearer  to  the  original  seat  of  the  disease.  The  symptoms 
and  clinical  course  of  interstitial  sarcoma  in  the  beginning  may  re- 
semble those  of  myoma  so  closely  as  to  make  the  clinical  diagnosis 
wholly  unreliable.  The  clinical  course  and  physical  signs  of  this 
variety  in  the  later  stages  are  almost  identical  with  those  of  cancer. 

Sareomatous  degeneration  of  myoma  (spindle-cell  sarcoma)  may  be 
suspected  : 

1.  When   hemorrhages  formerly  attributed  to  the  myoma  sud- 

denly increase  or,  having  ceased  for  a  considerable  time, 
begin  again. 

2.  When  after  the  onset  of  the  menopause  the  tumor  rapidly 

increases  in  size  and  becomes  softer. 

»Peck.    From  Playfair's  System  of  Gynecology. 


CHAPTER  XXX. 

TUMORS  OF  THE  UTERUS    (Continued). 

DECIDUOMA  MALIGNUM— CHORIO-EPITHELIOMA. 

Etiology  of  Deciduoma  Malignum. 

Deciduoma  malignum  is  confined  to  the  physiological  period  of 
maturity,  occurs  usually  between  the  ages  of  twenty  and  thirty-five, 
and  usually,  perhaps  always,  is  preceded  by  gestation  or  hydatidiform 
mole. 

Pathology  of  Deciduoma  Malignum. 

Deciduoma  malignum,  sometimes  designated  as  chorio-epithelioma, 
first  described  in  1889,^  differs  radically  from  all  other  neoplasms; 
the  essential  element  is  a  giant-cell  imbedded  in  a  sarcoma-like  tissue. 

The  growth  is  of  foetal  origin,^  "  the  tissue  entering  into  the  forma- 
tion of  it  being  :  1.  Syncytium — i.  e.,  the  uterine  epithelial  layer  of 
the  chorion.  2.  The  so-called  cellular  layer — layer  of  Langhans — 
i.  e.,  the  ectodermal  epithelial  layer  of  the  chorion."  The  disease  has 
been  designated  variously,  according  to  the  origin  of  the  growth. 

If  from  the  decidua  as  : 
Deciduoma  adenomatosum. 
Deciduoma  carcinomatosum. 
Deciduoma  sarcomatosum. 

If  from  the  chorion  as 
Chorioma  syncytiale, 
Chorioraa  sarcomatosum. 

Deciduoma  malignum  is  circumscribed,  reddish  brown,  and  friable ; 
it  presents  secondary  nodules,  and  commonly  extends  by  early  metas- 
tasis to  the  vagina,  ovaries,  broad  ligaments,  spleen,  kidney,  lungs, 
and  brain. 

The  growth  is  rich  in  blood-supply,^  and  the  blood  is  confined  wathin 
irregular  spaces ;  the  vessels  have  no  adequate  walls ;  hence  the  fre- 
quent hemorrhages.  Necrotic  changes  take  place  early.  Under  the 
necrosed  tissue  is  solid  tumor,  and  under  this  is  normal  uterine  tissue. 
In  the  development  of  the  growth  the  normal  constituents  of  the 
uterine  wall  are  replaced  rapidly  by  invasion  of  giant-cells  and  small 
round  cells. 

Symptoms  and  Diagnosis  of  Deciduoma  Malignum. 

Profuse  hemorrhage  occurring  during  the  puerperium  is  the  most 
characteristic  symptom  ;  it  is  intermittent  and  commonly  so  profuse 

1  Sanger.    A  System  of  Gynecology,  by  Playfair. 

2  Marchand.    From  Playfair's  System  of  Gynecology. 

3  H.  M.  Jones.    "  A  Clinical  and  Pathological  Study  of  Deciduoma  Malignum."    Johns  Hop- 
kins Hospital  Reports,  vol.  vi. 

434 


TUMORS  OF  THE   UTERUS.  435 

as  to  cause  profound  anseraia.  Curettage  gives  but  transient  relief. 
The  discharge  is  profuse,  watery,  and  often  foul-sraelling.  Hydatid- 
like  moles  may  be  discharged  with  added  hemorrhage.  The  uterus 
rapidly  enlarges.  Metastasis  takes  place  by  the  venous  route,  most 
commonly  to  the  lungs,  and  gives  rise  to  symptoms  referable  to  the 
newly  infected  part.  Anaemia,  emaciation,  and  cachexia  follow  in 
rapid  succession.  Even  though  the  disease  be  removed  by  early 
hysterectomy,  death  is  usual  in  a  few  months. 

Physical  examination  shows  an  enlarged  uterus.  Smooth,  secondary 
nodules  may  be  felt  on  the  tubes.  The  uterine  cavity  may  be  open 
sufficiently  to  admit  the  finger.  Digital  exploration  then  will  detect 
masses  of  soft  tissue  and  coagula  of  blood  usually  localized  in  the 
uterine  wall.  The  above  history  and  symptoms  are  highly  diag- 
nostic. Microscopical  examination  of  the  scrapings  will  establish  the 
diagnosis. 

Prognosis  of  Deciduoma  Malignum. 

Seventy-eight  per  cent,  of  all  cases  terminate  fatally  within  six 
months.     Deciduoma  malignum  is  the  most  malignant  of  all  tumors. 

Treatment  of  Deciduoma  Malignum. 

Prophylaxis  requires  thorough  removal  of  all  retained  products  of 
conception  and  prompt  attention  to  post-abortum  and  puerperal  liem- 
orrhages.  The  surgical  treatment  is  the  same  as  that  already  laid 
down  for  carcinoma,  viz.,  early  hysterectomy.  Some  radical  cures  have 
been  reported. 


CHAPTER  XXXI. 

SOLID  TUMORS  OF  THE  OVARY. 

Fibroma.    Myoma.    Sarcoma.    Carcinoma.    Benign  Papilloma. 

Solid  tumors  of  the  ovary,  like  some  ovarian  cysts  (intraliga- 
mentous), may  develop  between  the  folds  of  the  broad  ligament. 
More  commonly,  however,  solid  ovarian  tumors  lie  outside  of  the 
broad  ligament.  A  pedicle  connects  the  tumor  with  the  uterus,  and, 
as  in  ovarian  cyst,  is  made  up  of  the  broad  ligament,  oviduct,  ovarian 
ligament,  and  ovarian  vessels.  About  5  per  cent,  of  all  ovarian 
tumors  are  solid.  Solid  tumors,  even  though  not  malignant,  are  asso- 
ciated more  commonly  with  ascites  than  are  cystic  tumors. 

Fibromata  are  histologically  identical  with  similar  tumors  in 
other  organs.  Peterson  ^  has  collected  from  the  literature  84  cases ; 
he  finds  that  fibromata  are  not  so  rare  as  formerly  supposed,  and 
that,  contrary  to  the  usual  observation,  they  grow  sometimes  to  large 
size ;  his  paper  is  one  of  the  most  complete  studies  of  the  subject  yet 
published. 

Myomata  are  of  rare  occurrence.  They  are  composed  of  the 
usual  unstriped  muscle-fibre  and  fibrous  tissue — fibromyoma.  The 
muscle-fibre  is  traceable  from  the  ovary  to  the  ovarian  ligament.  Dis- 
tinction between  the  myoma  and  the  spindle-cell  sarcoma,  even  with 
the  microscope,  is  not  always  easy.  These  tumors  sometimes  grow  to 
large  size. 

Sarcomata  are  not  of  frequent  occurrence.  They  sometimes  occur, 
especially  in  childhood,  in  connection  with  dermoid  cysts,  or  follow 
the  removal  of  dermoids.  The  spindle-cell  is  more  frequent  than  the 
round-cell  variety.  As  in  sarcoma  elsewhere,  rapid  growth,  speedy 
degeneration,  and  metastatic  invasion  of  other  organs  characterize  the 
disease.  Both  ovaries  are  apt  to  be  involved  primarily  at  the  same 
time. 

Carcinoma. — Little  is  known  of  primary  carcinoma  of  the  ovary. 
It  arises  in  both  ovaries  at  the  same  time.  Secondary  carcinoma  may 
occur  by  extension  from  neighboring  organs  or  by  metastasis. 

Benign  Papillomata  (solid  warty  growth)  arise  from  the  outer 
surface  of  the  ovary ;  they  may  spread  to  the  peritoneum  and  broad 
ligaments,  and  may  undergo  malignant  changes.  See  Papillomatous 
Cysts  in  the  following  chapter. 

Diagnosis  of  Solid  Ovarian  Tumors. — Solid  ovarian  tumors  may  be 
recognized  one  from  the  other,  from  cystic  tumors,  and  from  other  pel- 
vic conditions  by  the  clinical  history,  conjoined  manipulation,  explora- 
tory  incision,  and   microscopical   examination.     The   clinical   history 

1  American  Gynecology,  July,  1902. 
436 


PLATE   XX 


Solid  Carcinoma  of  the  Ovary,  with  Extension  of  the  Disease 

to  the  Intestinal  and  Parietal  Peritoneum 

and  to  the  Omentum. 


SOLID   TUMORS  OF  THE  OVARY. 


437 


often  will  suffice  to  separate  the  malignant  from  the  benign  growths. 
Conjoined  examination  will  outline  a  tumor  in  the  ovarian  region, 
will  show  that  it  is  not  connected  with  the  uterus,  and  will  determine 
its  size,  form,  mobility,  and  consistence.  Exploratory  incision  will 
define  further  its  physical  characteristics  and  its  exact  relation  to 
adjacent  organs.     The  diagnosis  is  concluded  by  the  microscope. 


Figure  193. 

--^^ 

. 

rf 

j^ 

i 

w*^ 

1 

w% 

K 

i^^^^JHj^^ 

\^. 

\ 

\ 

.   ^ 

A 

y 

''^^^H 

i 

f 

"Tin^pi 

^q 

^H 

Solid  sarcoma  of  the  ovary,  weight  four  pounds.  Observe  the  smooth  cut  surface,  character- 
istic of  sarcoma,  as  compared  with  the  uneven  surface  of  a  uterine  myoma  in  Chapter  XXVI. 
Author's  case  ;  ovariotomy  ;  recovery. 

Treatment  of  Solid  Ovarian  Tumors. — The  treatment  of  very  small 
benign  growths  without  pressure-symptoms  or  functional  disturbance 
is  expectant.  That  of  large  benign  tumors  or  of  malignant  tumors 
is  early  removal.  The  operation  is  the  same  as  for  cystic  ovarian 
tumors.     See  Ovariotomy. 


CHAPTER   XXXII. 

CLASSIFICATION,  MODE  OF  DEVELOPMENT,  AND  PATH- 
OLOGY OF  OVARIAN  AND  PABOVARIAN  CYSTS,  AND 
OVARIAN  HYDROCELE. 

The  ovary  consists  of  two  parts  : 

1.  The  outer  cortical  or  egg-bearing  part,  called  the  Cortex  and 
containing  the  Graafian  follicles. 

2.  The  inner  zone,  which  never  contains  follicles  or  ova ;  this 
part  is  in  relation  with  the  hilum  of  the  ovary,  is  composed  of  fibrous 
tissue  and  traversed  by  numerous  blood-vessels,  and  is  called  the 
vascular  or  medullary  portion. 

In  relation  with  the  ovary  and  situated  in  the  broad  ligament  is  a 
remnant  of  the  Wolffian  body,  which  has  no  physiological  significance, 
called  the  Parovarium. 

Cystic  tumors  may  arise  : 

1.  From  any  portion  of  the  ovary — Ovarian  Cysts. 

2.  From  the  parovarium — Parovarian  Cysts. 

In  connnection  with  Figure  194,  the  student  is  referred  specially 
to  Embryology  in  Chapter  XXXVII. 

.       OVARIAN  CYSTS. 

Mode  of  Development  of  Ovarian  Cysts. 

Ovarian  cysts  may  be  : 

1.  Unilocular — monocysts. 

2.  Multilocular — polycysts. 

1.  Unilocular  Ovarian  Cysts  may  spring  from  the  Graafian  folli- 
cles, the  corpus  luteum,  or  may  be  simple  cyst-adenomata.  They 
are  not  very  common.  Some  ovarian  tumors  classed  as  monocysts 
may  have  apparently  a  single  cavity,  but  close  examination  usually 
will  show  numerous  small  loculi  in  their  walls.  Sometimes,  as 
stated  by  Sutton,  imperfect  septa  or  bands  running  from  one  part 
of  the  cyst-wall  to  another  are  remnants  of  these  walls  and  show  that 
the  cyst  originally  was  multilocular.  Parovarian  cysts,  which  are 
usually  unilocular,  have  often  been  mistaken  for  unilocular  ovarian 
cysts  ;  hence  the  impression  that  the  latter  are  quite  common.  Uni- 
locular cysts,  although  usually  small,  may  have  a  capacity  of  several 
gallons. 

2.  Multilocular  Ovarian  Cysts  are  common,  and  will  be  de- 
scribed under  multilocular  cyst-adenomata. 

Ovarian  cysts  are  divided  according  to  their  origin  or  character  as 
follows  : 

438 


CLASSIFWA  TIONS. 


439 


1.  Follicular  cysts  (degenerated  Graafian  follicles). 

2.  Corpus  luteum  cysts  (unilocular). 

3.  Cyst-adenomata,  subdivided  as  follows  : 

a.  Simple. 
6.  Papillary. 

4.  Dermoid  cysts. 

Follicular   cysts,    corpus   luteum    cysts,  and   cyst-adenomata  are 
epithelium  neoplasms. 

Figure  194. 


^-^         ^^^^^»»»'^-'***-«**>«»^J 


K 


V   A  ROVA  i?  /  ^;^ 


Cyst-producing  region  of  the  ovary  and  its  surroundings : 

A.  Uterus,  Fallopian  tube,  parovarium,  and  ovary. 

B.  Gaertner's  duct  (remnant  of  Wolffian  duct),  parovarium  (remnant  of  WolfiBan  body  or 
mesonephros),  and  ovary  shown  in  section:  p,  vascular  or  medullary  zone ;  o,  oophoron — this 
is  the  egg-bearing  portion,  sometimes  called  parenchymatous  zone,  sometimes  the  cortical  por- 
tion ;  s,  tree  external  surface  of  ovary ;  k,  Kobelt's  tubes.    Semi-diagrammatic. 


1.  Follicular  Ovarian  Cysts. 

Follicular  cysts  due  to  inflammatory  changes  and  shown  in  Fig- 
ure 195  as  microcystic  degeneration  of  the  ovary  have  been  described 
in  the  chapter  on  Ovaritis.  Putting  aside  the  possible  relations  of 
these  retention-cysts  to  ovarian  tumors,  we  may  describe  a  genuine 
follicular  cystic  neoplasm,  which  may  cause  considerable  enlargement 


440  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS. 

of  the  ovary.  A  mlmber  of  follicles  take  on  cystic  degeneration, 
giving  rise  to  many  small  adjacent  cysts  which  may  by  the  destruc- 
tion of  the  partitions  between  them  run  together  and  form  one  or 
more  larger  cysts. 

The  wall  of  a.  follicular  cyst  is  composed  of  three  layers  :  an  outer 
layer  of  endothelial  cells  or  in  small  growths  of  cuboidal  epithelium. 
A  middle  layer  of  Avhite  fibrous  tissue  containing  blood-vessels  and 
lymphatics,  an  inner  layer  of  membrana  granulosa  like  that  of  the 
Graafian  follicle.  This  membrana  granulosa  is  maintained  until  the 
cyst  reaches  the  approximate  size  of  an  egg.  In  tumors  the  size  of 
an  orange  the  lining  layer  changes  finally  to  a  flat  epithelium.     In 

Figure  195. 


Microcystic  degeneration  of  the  orary  ;  the  ovary  to  the  right  shows  numerous  small  cysts 
scattered  over  the  surface  ;  these  are  Graafian  follicles  which  have  undergone  cystic  degenera- 
tion, and  which  it  is  said  may  take  on  excessive  growth  and  develop  into  large  tumors,  or  may 
remain  as  here  represented;  on  the  other  side  is  shown  a  similar  condition  of  the  ovary  in 
section. 

large  cysts  containing  much  more  fluid  the  epithelium  disappears 
by  atrophy  and  gives  way  to  fibrous  tissue.  The  atrophic  process  is 
due  to  pressure  of  the  fluid  contents.  The  fluid  is  apt  to  be  identical 
with  mucus,  a  fact  doubtless  owing  to  the  lining  of  epithelium. 

2.  Corpus  Luteum  Cysts. 

The  wall  of  a  corpus  luteum  cyst  sometimes  may  be  recognized  by 
the  wavy  aspect  and  yellow  color  of  its  inner  surface.  The  external 
layer  is  composed  of  connective-tissue  stroma  containing  blood-  and 
lymph-vessels  around  which  at  many  points  are  groups  of  round  cells  ; 
these  vessels  pass  perpendicularly  to  the  middle  layer  which  contains 
as  a  characteristic  of  this  form  of  cyst,  lutein  cells.  The  inner  layer 
shows  cellular  elements  which  are  undergoing  retrogressive  changes 
and  is  not  distinctly  separable  from  the  cyst-contents.  These  cysts 
are  usually  small,  rarely  growing  to  the  size  of  an  orange.  They  com- 
monly have  a  thick  wall  and  contain  a  watery,  yellow  fluid  which  is 
said  to  get  its  color  from  the  pigment  of  the  lutein  cells.  Corpus 
luteum   cysts  are  monocystic. 


CLASSIFICA  TIONS. 


441 


3.  Cyst-adenomata. 

Cyst-adenomata,  often  caWeA  proliferating  cysts,  the  most  common 
form  of  ovarian  tumors,  unlike  follicular  cysts,  frequently  grow  to 
enormous  size.  They  are  characterized  by  excessive  rapid  growth 
and  by  having  the  capacity  to  secrete  great  quantities  of  fluid,  and 
are  divided  into  : 

a.  Simple  cyst-adenomata,  which  have  smooth  inner  M'alls. 

b.  Papillary  cyst-adenomata,  the  inner  walls  of  which  produce 
warty  growths. 

a.  Simple  Cyst-adenomata  may  be  unilocular  or  multilocular. 
As  in  follicular  cysts  the  compartments  between   the  cavities  of  a 


Cyst-adenoma.    Multilocular  ovarian  cyst,  sometimes  called  ovarian  adenoma. 

multilocular  cyst  may  disappear  and  form  a  single  cystic  cavity,  so 
that  a  multilocular  cyst  may  become  unilocular.  The  multilocular 
cyst  usually  has  one  large  primary  cavity  and  a  number  of  smaller 
adjacent  cavities,  which  have  formed  in  the  walls  of  the  original  cyst. 
The  simple  cystic  development  may  increase  until  the  tumor  becomes 
enormous,  a  burden  to  the  patient  and  a  destroyer  of  life. 

In  these  simple  adenomatous  tumors  the  walls  are  traversed  by 
large  blood-vessels  and  are  lined  with  glandular  cylindrical  epithelium 
sometimes  ciliated,  which  continuously  produces  large  quantities  of 
fluid  and  preserves  its  integrity  in  spite  of  the  pressure  exerted  upon 
it  by  the  cyst-contents.  Adenomatous  cysts  of  the  ovary  have  some 
tendency  to  become  malignant ;  hence  the  importance  of  early  re- 
moval.    The  walls  are  more  or  less  thick  according  to  the  degree  of 

27 


442  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

distention,  and  are  composed  largely  of  connective  tissue.  Cyst-ade- 
nomata usually  contain  a  thin  clear  sticky  fluid  which  from  admixture 
of  blood  may  become  red  or  chocolate  colored,  and  in  which  chemical 
tests  show  the  presence  of  pseudomucin.  Figures  196  and  197  show 
two  views  of  a  cyst-adenoma,  one  of  which  is  in  section. 

6.  Papillary  Cyst-adenomata. — Papillomatous  cysts  more  com- 
monly develop  in  the  hilum  or  in  the  medullary  portion  of  the  ovary. 
They  usually  contain  a  clear,  thin,  yellowish  fluid,  which  may  be  red- 
dish from  admixture  of  blood.  In  chemical  properties  and  micro- 
scopical appearance  this  fluid  resembles  that  of  ordinary  cysts.     The 

FiGlXRE  197. 


Cyst-adenoma.    Multilocular  ovarian  cyst,  sometimes  called  ovarian  adenoma,  in  section  ;  the 
larger  cavity  is  primary ;  the  smaller  cavities,  secondary. 

fluid  may  be  mixed  with  a  tenacious  colloid  formation.     These  cysts 
have  the  following  characteristics  : 

They  are  rare  before  the  twenty-fifth  year,  more  common  between 
the  ages  of  thirty  and  fifty  ;  seldom  attain  the  size  of  ordinary  ovarian 
cysts  ;  are  usually  unilocular  and  frequently  develop  between  the 
layers  of  the  mesosalpinx.  With  increased  growth  they  may  separate 
the  layers  of  the  broad  ligament  and  force  their  way  between  them  to 
the  lateral  walls  of  the  uterus,  and  will  then  feel  on  digital  touch 
like  an  outgrowth  from  the  uterus.  They  present,  especially  on  the 
inside,  in  variable  quantity,  warty  or  papillomatous  growths,  which 
histologically  are  the  same  as  warty  growths  in  other  parts  of  the 


CLASSIFICA  TIONS. 


443 


body,  and  which  may  penetrate  the  cyst-wall  to  the  peritoneum  and 
to  adjacent  organs. 

The  cyst-wall  is  composed  of  the  usual  fibrous  tissue,  which  has  an 
inner  lining  of  cylindrical  epithelium.  The  source  of  this  epithelium 
is  not  definitely  known.  It  is  thought  by  some  to  be  from  remnants  of 
epithelium  from  the  Wolffian  body.  At  any  rate  it  has  the  power  of 
producing  a  most  abundant  warty  growth. 

The  characteristic  of  papillomatous  cystic  tumors  is  the  warty 
growth,  which  proliferates  rapidly,  bleeds  freely  on  manipulation,  is 
usually  soft  and  friable,  varies  in  quantity  from  that  of  the  smallest 
wart  to  that  of  an  orange,  may  be  either  sessile  or  pedunculated,  and 
according  to  the  variable  blood-supply,  pale  or  pink.  These  papillo- 
matous elements  may  so  increase  in  quantity  as  to  force  their  way  by 
rupture  or  perforation  through  the  cyst-wall,  spread  over  the  outside, 

Figure  198. 


Papillomatous  ovarian  disease.  On  the  right  side  is  a  cyst  from  the  vascular  zone 
of  the  ovary;  in  the  wall  of  this  cyst  have  developed  three  secondary  cysts,  which  are 
shown  in  section  and  which  contain  warty  growths;  observe  also  the  warty  growths  both  on 
the  outside  and  inside  of  the  cyst ;  to  the  left  is  a  superficial  papilloma  of  the  ovary,  which  lies 
between  the  ovary  and  the  uterus.  Papillomatous  disease  on  the  inside  of  this  ovary  is  also 
shown  in  section. 


and  affect  the  adjacent  peritoneum.  Extension  of  the  disease  is  by 
continuity  of  tissue  or  surface,  not  by  way  of  the  vessels.  Warty 
ovarian  cysts  may  be  associated  with  dermoids,  and  occasionally  with 
sarcoma  of  the  ovary.  Tapping  of  the  cyst  is  contraindicated,  for  if 
fluid  escapes  into  the  abdominal  cavity,  the  peritoneum  may  be 
infected ;  hence  in  removal  care  should  be  used  to  prevent  the 
escape   of  fluid. 

It  should  be  noted  in  this  connection  that  other  papillomatous 
tumors  found  in  the  ovary  and  Inroad  ligaments  have  not  developed 
from  the  medullary  portion  or  hilum  of  the  ovary ;  these  cysts,  ac- 
cording to  Sutton,  differ  as  follows  from  the  warty  cysts  just 
described  : 

1.  They  may  be  in  any  part  of  the  ovary. 

2.  They  are  usually  multiple. 


444  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS. 

3.  The  warts  are  of  almost  cartilaginous  hardness. 

4.  They  are  associated  frequently  with  uterine  myomata. 
Clinically  speaking,  papilloma  of  the  uterine  appendages,  whether 

solid  or  cystic,  is  on  the  border  line  between  benign  and  malignant 
growths.  Frequent  tappings  extending  over  a  period  of  several 
years  have  been  recorded  in  connection  with  inoperable  cases.  The 
stronger  the  malignant  tendency,  the  more  pronounced  the  ascites. 
Papillomata  may  give  rise  to  great  embarrassment  in  the  removal  of 
the  tumor,  for  if  any  of  the  warty  growths  are  left  behind  they  are 
apt  to  spread  rapidly  and  render  the  operation  useless.  On  the  con- 
trary, if  they  are  all  removed  the  ascites  may  be  expected  to  dis- 
appear and  the  patient  to  become  permanently  well.  Even  in  the 
cases  of  extensive  warty  development,  if  there  is  hope  of  complete  re- 
moval, the  radical  opei'ation,  even  to  the  extent  of  combined  ovariotomy 
and  hysterectomy,  should,  be  attempted. 

4.  Dermoid  Ovarian  Cysts. 

Dermoid  ovarian  cysts  are  distinguished  from  follicular  cysts  and 
cyst-adenomata  by  the  inner  lining  of  the  cyst-wall,  which  is  made 
up  of  squamous  epithelium  and  papillse  like  external  skin.  The  cyst- 
wall  contains  an  outer  layer  of  connective  tissue.  Dermoid  cysts 
are  found  not  only  in  the  ovary  but  also  in  various  other  parts  of  the 
'  body.  The  quantity  of  dermoid  elements  is  variable.  Cutaneous 
structures  may  line  an  entire  cyst  or  may  be  confined  to  small  isolated 
areas.  Sometimes  dermoid  elements  are  contained  in  a  single  small 
compartment  of  a  large  multilocular  cyst-adenoma  and  the  dermoid 
character  of  the  growth  may  then  be  overlooked.  Two  classes  are 
recognized  : 

1.  Simple  dermoid  cysts. 

2,  Complicated  dermoid  cysts — teratomata. 

Simple  Dermoid  Cysts. — The  simple  dermoid  cyst  has  a  very 
distinct  inner  lining  of  integument,  consisting  of  flat  epithelium, 
papillae,  and  sabaceous  glands.  The  cyst-wall  and  the  cyst-cavity 
contains  dermoid  elements,  such  as  hair,  skin,  nails,  sebaceous  matter, 
and  a  yellowish  fat.  As  a  rule,  these  tumors  do  not  grow  to  the 
great  size  of  cyst-adenomata.  The  hair  is  sometimes  present  in  great 
abundance,  and  may  be  matted  together  in  the  form  of  a  round  ball 
the  size  of  an  orange.  According  to  Sutton,  the  color  is  variable, 
does  not  necessarily  correspond  with  that  of  the  head  of  the  patient, 
and  in  aged  people  may  be  gray  or  may  have  been  shed,  leaving  the 
wall  of  the  cyst  bald.  Extensive  involvement  of  both  ovaries  in 
dermoid  cystic  disease,  even  though  little  normal  ovarian  tissue  re- 
mains, does  not  positively  render  the  woman  sterile.  In  one  case, 
reported  by  Cullingworth,  the  patient,  at  the  age  of  thirty-nine,  had 
had  twelve  children,  the  last  being  three  months  old  at  the  time  of 
the  removal  of  the  two  dermoid  ovaries. 

Dermoid  tumors  occur  at  all  ages,  from  infancy  to  extreme  senility. 
They  occasionally  are  found  in  children,  and  are  not  uncommon  in 
young  women.     Unlike  other  forms  of  ovarian  cysts  which  destroy 


CLASSIFICA  TIONS. 


445 


life  in  three  or  four  years,  simple  dermoids  may  exist  for  a  lifetime 
and  give  little  or  no  inconvenience.  They  have  been  found  post- 
mortem in  aged  women,  who  may  have  had  them  from  the  period  of 
sexual  maturity  and  never  been  aware  of  their  presence.  Like  other 
cysts,  however,  they  may  at  any  time  undergo  suppurative  malignant 
and  other  degenerative  changes  and  therefore  become  dangerous. 

The  fluid  content  of  a  pronounced  dermoid  cyst  is  an  oily  fat, 
which  is  fluid  at  the  temperature  of  the  body,  but  at  a  lower  tempera- 
ture, semisolid.  The  fatty  contents  are  very  irritating  to  the  perito- 
neum, and  when  a  cyst  breaks  into  the  peritoneal  cavity  the  epithelial 

Figure  199. 


Dermoid  ovarian  cyst  in  section,  showing  inside  of  cyst-cavity,  which  contains  a  lower  jaw 
and  a  fragment  of  another  jaw,  with  teeth,  small  fragments  of  bone,  and  considerable  hair; 
the  upper  mass  of  hair  is  in  the  shape  of  a  baU.and  is  held  together  by  the  fatty  contents  of  the 
cyst,  which,  at  the  temperature  of  the  body,  is  liquid,  but  becames  solid  upon  exposure  to  the 
ordinary  temperature  of  the  air,  that  is,  about  70°  F. 

elements  of  it  may  engraft  themselves  upon  the  peritoneum  and  give 
rise  to  secondary  growths. 

2.  Complicated  Dermoid  Cysts  (Teratomata). — In  addition  to 
the  dermoid  elements  mentioned  above,  dermoid  cysts  may  contain 
other  structures  of  the  body,  such  as  bones,  teeth,  fragments  of  the 
brain,  muscle,  and  cartilage,  even  an  entire  finger  has  been  observed. 
Such  tumors  are  apt  to  be  of  the  solid  rather  than  of  the  cystic 
variety,  and  are  called  teratomata .  The  presence  of  bone  and  teeth 
does  not  characterize  them  as  especially  inclined  to  malignant  degen- 
eration, but  when  numerous  other  embryonal  structures  of  the  difier- 


446  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS. 

ent  layers  of  the  blastoderm,  brain,  muscle,  nerve,  cartilage,  fat,  and 
bone  are  thrown  together  throughout  the  tumor  in  a  confused  mass 
the  growth  should  be  regarded  as  having  a  decided  malignant  ten- 
dency. Teratomata  have  been  classified  as  simple  growths,  which  con- 
tain dermoid  elements,  teeth  and  bone,  and  as  complicated  growths 
which  contain  the  other  structures  above  mentioned. 

Formation  of  Pedicle  of  an  Ovarian  Cyst. 

Most  ovarian  cysts  are  pedunculated,  the  pedicle  being  made  up 
of  structures  which  connect  the  cyst  Avith  the  uterus,  broad  ligament, 
round  ligament,  Fallopian  tube,  ovarian  artery,  and  ovarian  vein. 

PAROVARIAN  CYSTS. 

The  parovarium  from  which  parovarian  cysts  spring  is  the  remnant 
of  the  Wolffian  body  (primitive  kidney)  and  has  no  known  physiological 
significance.    The  epididymis  and  vasa  efferentia  in  the  male  also  spring 

Figure  200. 


Small  parovarian  cvst.  This  cyst  has  sprung  from  the  parovarium,  and  istherefure  entirely 
distinct  from  the  ovary";  to  the  right  is  the  hydatid  of  Morgagni  suspended  from  a  long,  slender 
pedicle,  which  is  attached  to  one  of  the  fimbriated  extremities  of  the  Fallopian  tube.  The 
hydatid  of  Morgangi  has  been  known  to  grow  to  the  size  of  a  small  orange,  and  it  then  has  the 
same  general  appearance  as  the  parovarian  cyst,  but  is  distinguished  from  it  by  the  fact  that  it 
springs  from  the  extremity  of  the  Fallopian  tube.  The  Fallopian  tube  shows  numerous  points 
of  expansion  and  constriction,  one  of  them  being  at  the  isthmus;  this  is  known  as  salpin- 
gitis isthmica  nodosa,  common  in  gonorrhceal  salpingitis.  Myoma  and  adenomyoma  of  the 
tube  present  a  gross  appearance  similar  to  that  of  salpingitis  isthmica  nodosa.  This  condition 
of  the  tube  is  rarely  found  in  connection  with  cysts  of  the  parovarium. 

from  the  Wolffian  body  and  are  the  homologue  of  the  parovarium.  If 
the  broad  ligament  is  stretched  and  held  up  to  the  light,  a  series  of  small 
tubules  will  be  seen  radiating  from  the  ovary  and  joining  at  right 
angles  a  longitudinal  tube.  The  tubules  are  the  parovarium.  See 
Figure  194.  They  are  of  two  kinds:  1.  The  vertical  tubules. 
2.  The  outer  tubules,  free  at  one  end — Kobelt's  tubes.  All  these 
tubules  join  a  longitudinal  tube — Gaertner's  duct.  This  duct  is  the 
homologue  of  the  vas  deferens  in  the  male ;  occasionally  it  may  be 
traced  downward  to  the  vagina.  The  parovarium  lies  between  the 
folds  of  the  mesosalpinx. 


CLASSIFICA  TIONS. 


447 


The  little  tubules  of  Kobelt  very  often  are  distended  by  their  fluid 
contents  into  cysts,  usually  not  larger  than  a  pea.  These  cysts,  which 
have  little  or  no  significance,  frequently  are  confounded  with  the 
hydatid  of  Morgagni.  Figure  200.  A  distended  vertical  tubule 
may  become  separated  and  form  a  pedunculated  cyst.  This  may 
rupture,  discharge  its  contents  into  the  abdominal  cavity,  and  become 
obliterated.  The  remnant  of  the  cyst- wall  then  presents  a  fringe-like 
appearance.     See  ,Chapter  XXXVII. 

Figure  201. 


Parovarian  cyst.   Observe  the  ovary  separate  from  the  cyst  and  the  longr,  stretcued-out  Fallopian 
tube  whicli  surrounds  the  cyst-wall. 

The  usual  parovarian  cyst  is  unilocular,  that  is,  it  springs  from  a 
single  vertical  tubule,  and  most  commonly  develops  without  a  pedicle, 
and  remains  between  the  layers  of  the  mesosalpinx.  As  it  grows  larger 
it  may  force  its  way  between  the  layers  of  the  broad  ligament  and 
lies  in  close  relation  with  the  uterus.     The  Fallopian  tube,  with  its 


448 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


fimbriated  extremity  attached  to  the  ovary  and  its  uterine  end  to  the 
uterus,  is  stretched  over  the  enlarging  cyst-wall,  and  the  tube  in  this 
way  is  often  enormously  elongatea. 

The  walls  of  small  cysts  are  usually  quite  thin  and  transparent ; 
when  larger  they  become  thick,  opaque,  pearly-like,  and  of  conjunc- 
tival blue  color.  The  lining  of  the  small  cysts  preserves  the  columnar 
epithelium  of  the  tubule ;  in  larger  cysts  the  epithelium  becomes  flat- 
tened ;  in  the  largest  cysts  the  atrophic  influence  of  pressure  is  so 
great  as  entirely  to  destroy  the  epithelium. 

Figure  202. 


Ovarian  hydrocele,  natural  size. 


The  tortuous,  retort-shaped  Fallopian    tube  connects  the 
tumor  with  the  uterus. 


Unlike  the  ovarian  cyst,  which  is  a  diseased  ovary,  the  parovarian 
cyst  usually  has  a  normal  ovary  attached  to  the  side  of  it.  The  fluid 
is  almost  always  clear  and  colorless,  like  spring-water;  the  nitric- 
acid  and  heat  tests  may  show  a  trace  of  albumin.  The  specific  gravity 
is  usually  much  less  than  1010.  The  reaction  is  faintly  acid.  See 
Tabular  Diagnosis  between  Parovarian  and  Ovarian  Cysts,  in  the 
following  chapter.  Adhesions  rarely  form  about  these  cysts.  The 
peritoneal  covering  is  stripped  oif  easily,  and  the  cyst,  therefore,  easily 
enucleated. 


CLA  SSIFIGA  TIONS. 


449 


The  parovarium  does  not  often  take  on  demonstrable  cystic  disease 
before  the  age  of  puberty,  the  more  common  age  for  development 
being  from  eighteen  to  thirty-five.  These  cysts  do  not  tend  to  rapid 
degeneration,  and  therefore  may  be  carried  for  years  with  little  or  no 
danger.  Rupture  or  tapping  sometimes  is  followed  by  obliteration 
and  cure. 

Cyst  of  the  Broad  Ligament  is  a  name  reserved  by  many  to  desig- 
nate parovarian  cysts.  Various  other  cysts,  however,  also  develop  in 
the  broad  ligament.  The  name,  therefore,  has  no  definite  significance 
beyond  the  fact  that  it  designates  a  cyst  situated  between  the  layers 
of  the  ligament.    Such  a  cyst  may  originate  in  the  ovary  and  gradually 

Figure  203. 


Tubo-ovarian  cyst.    The  genesis  of  this  cyst  is  set  forth  in  Chapter  XXI.    Sometimes  the  sac  of 
a  tubo-ovarian  cyst  suppurates  ;  it  is  then  known  as  a  tubo-ovarian  abscess. 


force  its  way  between  the  folds  of  the  broad  ligament.  It  not  uncom- 
monly originates  near  the  hilum  of  the  ovary,  and  the  great  majority 
of  broad  ligament  cysts  are  either  of  this  sort  or  parovarian.  When 
they  are  of  ovarian  origin  they  are  called  intraligamentous  ovarian 
cysts. 

The  Hydatid  of  Morgagni  may  grow  to  such  considerable  size  as 
to  be  a  mechanical  irritant  and  require  removal. 


450 


TUMOBS,   TUBAL  PBEGNANCY,  MALFOBMATIONS. 


OVARIAN  HYDROCELE. 

Ovarian  hydrocele  is  a  rare  and  curious  disease,  in  which  the  dilated 
Fallopian  tube  communicates  by  its  abdominal  opening  with  the  cavity 
of  a  cyst.  The  opening  is  usually  large  and  circular.  According  to 
Bland  Sutton/  the  formation  of  the  cyst  is  analogous  to  that  of  hydro- 
cele in  the  male.  He  gives  evidence  to  show  that  it  arises  in  a  tunic 
of  peritoneum,  which  sometimes  invests  the  ovary  as  the  tunica  vagi- 
nalis covers  the  testis. 

Ovarian  hydrocele  may  suppurate,  and  may  then  easily  be  con- 
founded with  a  tubo-ovarian  abscess.     The  treatment  is  ovariotomy. 

Ovarian  hydrocele  has  been  confounded  hitherto  with  tubo-ovarian 
cyst.  The  distinctions  between  these  two  cysts,  made  by  Bland  Sutton, 
are  shown  in  the  following  tabular  statement : 


Ovarian  hydrocele. 

1.  Salpingitis  has  nothing  to  do  with  the 
cause,  although  it  may  be  present  as  a  compli- 
cation. 

2.  The  opening  between  the  tube  and  sac  is 
large  and  round  or  oval,  and  is  the  dilated  ab- 
dominal opening  of  the  tube. 


3.  The  tube,  not  large,  is  usually  tortuous, 
like  the  worm  of  a  retort. 

4.  There  is  apt  to  be  an  intermitting  dis- 
charge of  fluid  from  the  tube  through  the 
uterus. — hydrops  tubx  profliiens. 


Tubo-ovarian  cyst. 

1.  Salpingitis  is  a  cause  of  the  communica- 
tion between  the  tube  and  ovarian  cyst.  See 
Chapter  XXI. 

2.  The  opening  is  variable  in  size,  and  usu- 
ally does  not  correspond  to  the  abdominal  os- 
tium; if  the  cyst  is  purulent — i.  e.,  if  it  is  a 
tubo-ovarian  abscess — the  opening  is  usually 
small. 

3.  The  tube  is  usually  larger  and  not  tor- 
tuous. 

4.  The  intermitting  discharge— salpingitis pro- 
fiuens — not  common. 


I  Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes. 


CHAPTER    XXXIII. 

SECONDARY  CHANGES  —  SYMPTOMATOLOGY— DIAGNOSIS, 
PROGNOSIS,  AND  DIFFERENTIAL  DIAGNOSIS  OF 
OVARIAN  AND  PAROVARIAN    CYSTS. 

SECONDARY  CHANGES. 

The  principal  secondary  changes  in  ovarian  and  parovarian  cysts 
are  : 

1.  Infection. 

2.  Twisting  of  the  pedicle. 

3.  Rupture  of  the  cyst. 

In  addition  to  the  above  secondary  changes  may  be  mentioned  the 
following  degenerative  changes  in  the  cyst-wall : 

1.  Fatty  degeneration. 

2.  Calcareous  degeneration. 

3.  Myxomatous  degeneration. 

4.  Malignant  degeneration  (sarcoma  and  carcinoma). 

Changes  in  the  fluid  contents  of  a  cyst  may  occur  as  follows  :  The 
fluid  naturally  contained  in  an  ovarian  cyst  is  usually  transparent, 
clear,  of  a  light-straw  color,  and  of  a  specific  gravity  varying  from 
1010  to  1050.  In  the  progress  of  the  disease  secondary  changes  occur 
which  make  the  widest  variation  in  the  physical  properties  of  the 
fluid.  This  variation  is  caused  by  the  admixture  of  blood,  pus,  fat, 
epithelial  cells,  cholesterin,  and  chemical  changes.  The  fluid,  there- 
fore, may  be  thick,  thin,  dark,  light,  clear,  muddy,  or  chocolate-col- 
ored. Different  fluids  may  be  present  in  the  different  compartments 
of  the  same  cyst. 

1.  Infection. 

The  sources  of  infection  from  which  bacteria  may  reach  the  cyst 
are  the  adjacent  organs — viz.,  an  adherent  Fallopian  tube,  urinary 
bladder,  intestine,  the  blood.  Formerly,  when  tapping  and  aspiration 
were  frequent  and  asepsis  was  disregarded,  infection  was  introduced 
frequently  by  the  puncture.  Small  cysts  that  remain  fixed  in  the 
pelvis  in  close  relations  with  the  pelvic  viscera  are  more  subject  to 
infection  than  the  large  growths  that  fill  the  abdomen.  When  adhe- 
sions occur  in  large  cysts  they  are  usually  stronger  and  more  extensive 
in  the  pelvis  than  in  the  abdomen. 

The  Fallopian  tube  is  doubtless  the  greatest  carrier  of  infection. 
This  may  be  inferred  from  the  fact  that  when  an  infected  cyst  be- 
comes adherent  to  adjacent  organs  the  strongest  adliesions  are  usually 
where  infection,  if  it  came  through  the  tube,  would  first  reach  the 
cyst — viz.,  about  the  abdominal  end  of  the  tube.     The  inference  is 

451 


452  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

strengthened  by  the  almost  constant  presence  of  salpingitis  in  con- 
nection with  infection  of  the  cyst-wall.  Inflammation  and  conse- 
quent adhesions  from  this  source  are  not,  however,  confined  to  the 
neighborhood  of  the  tube  ;  they  may  extend  indefinitely  over  the 
tumor,  gluing  it  to  any  adjacent  peritoneal  surface,  visceral  or  parietal, 
and  the  infection  may  even  penetrate  the  cyst-wall. 

The  intestine  and  bladder,  if  inflamed,  are  prolific  sources  of 
infection.  The  inflamed  gut  readily  adheres  to  the  cyst-wall,  and 
becomes  softened  by  the  inflammatory  process  or  thin  from  the 
atrophic  results  of  pressure.  Germ-bearing  gas,  according  to  Sutton, 
may  pass  into  the  cyst  and  set  up  suppurative  inflammation  of  the 
sac,  or  the  adherent  gut  and  sac-walls  may  become  perforated ;  the 
sac-contents  will  then  escape  by  way  of  the  bowel.  Extensive  infec- 
tion of  a  cyst  may  be  traceable  in  some  cases  to  an  inflamed  adherent 
vermiform  appendix. 

Suppuration. — Inflammation  of  the  cyst  may  go  on  to  sup- 
puration and  to  the  formation  of  extensive  adhesions.  In  acute 
suppuration  the  symptoms  rapidly  become  grave ;  they  are  : 

1.  Sudden  enlargement  of  the  tumor. 

2.  Severe  pain  and  tenderness. 

3.  Rapid  and  weak  pulse, 

4.  High  temperature  and  exhaustion. 

Acute  nephritis,  with  albuminuria,  is  a  frequent  complication.  In 
some  cases  putrefaction  leads  to  the  formation  of  gases  in  the  cyst,  when 
a  tympanitic  note  will  be  elicited  by  percussion  over  the  tumor.  In 
rare  cases  rupture  of  the  sac  and  the  discharge  of  its  purulent  con- 
tents through  the  intestine  or  some  other  viscus  may  avert  the  other- 
wise fatal  resuh.     Uusually  the  only  hope  lies  in  prompt  ovariotomy. 

Adhesions  are  among  the  most  constant  results  of  inflammation. 
Formerly  they  were  the  bUe  noir  of  the  surgeon.  Now,  with  improved 
technique,  tumors  that  formerly  would  have  been  abandoned  after  an 
exploratory  incision  are  removed  almost  always.  Adhesions  may  be 
abdominal  or  pelvic,  visceral  or  parietal.  Visceral  adhesions  are  those 
which  unite  the  tumor  to  the  uterus,  bladder,  liver,  and  other  abdo- 
minal or  pelvic  viscera.  Adhesions  to  the  omentum  are  common  and 
often  extensive.  Intestinal  adhesions  sometimes  gives  rise  to  danger- 
ous, even  fatal,  obstruction  of  the  bowel.  Pelvic  adhesions  are  more 
inaccessible,  and  therefore  more  dreaded  than  parietal.  Two  large 
ovarian  cysts,  one  from  the  right  and  the  other  from  the  left  ovary, 
may  come  in  contact  with  each  other  and  become  strongly  and  broadly 
united.  The  difliculties  of  diagnosis  and  operative  removal  are  then 
much  increased. 

2.  Twisting  of  the  Pedicle. 

Rotation  of  the  cyst,  with  consequent  twisting  of  the  pedicle,  is  an 
occasional  and  serious  accident. 

Acute  Torsion  is  a  sudden  rotation  of  the  cyst  with  sufficient  twist- 
ing of  the  pedicle  to  cut  oif  circulation  and  set  up  grave  symptoms. 

Chronic  Torsion  is  a  slow  rotation  of  the  cyst,  with  gradual  twist- 
ing of  the  pedicle.     This  gives  the  tumor  an  opportunity  to  readjust 


SECONDARY  CHANGES.  453 

itself  to  the  changed  conditions.  The  symptoms  are  less  severe  and 
the  course  more  prolonged  than  in  acute  torsion.  The  impaired  circu- 
lation may  be  restored  partially  through  adhesions.  The  pedicle  in 
rare  cases  is  twisted  off  completely.  The  detached  tumor  then  must 
receive  its  blood-supply,  if  at  all,  by  way  of  vessels  which  reach  it 
only  through  adhesions. 

Etiology. — Among  the  probable  causes  are  : 

1.  Alternate  distention  and  evacuation  of  the  bladder  or  bowel. 

2.  A  fall  or  other  violence. 

3.  Violent  exertion  ;  tight  lacing. 

4.  Growing  pregnant  uterus. 

5.  Long,  slender  pedicle,  especially  if  associated  with  ascites. 
Pathology. — The  pathological  results  of  torsion  are  : 

1.  CEdema  from  obstruction  to  the  circulation   in  the  sac-wall 

due  to  compression  of  bloodvessels  as  they  pass  through 
the  twisted  pedicle. 

2.  Engorgement,  which  may   cause   only  occasional   extravasa- 

tions of  blood  from  small  vessels  ;  or  may  be  so  intense  as 
to  cause  rupture  of  larger  vessels,  and  consequent  profuse 
hemorrhage  into  the  sac  and  great  distention  and  rupture 
of  the  cyst-wall,  and  discharge  of  the  cyst  contents  into  the 
abdomen. 

3.  Strangulation  of  the  cyst,  which  may  result  in  : 

1.  Gangrene  of  the  cyst. 

2.  Atrophy  of  the  cyst,  rare  and  only  in  small  tumors. 

3.  Separation  of  the  tumor  from  the  pedicle. 

4.  Peritonitis  with  possible  obstruction  of  the  bowel  from 

adhesions. 
Diagnosis. — The  diagnostic  signs  are  not  positive ;  they  are  : 

1.  Sudden  abdominal  pain  and  increase  in  the  size  of  the  tumor, 

cyst  growing  more  and  more  tense  and  the  pain  more  acute. 

2.  Rupture  of  the  sac,  recognized  by  sudden  disappearance  of 

the  enlarging  tense  cyst. 

3.  Symptoms  of  peritonitis  following  the  above  conditions. 
Prognosis. — Rotation,  if  sufficiently  acute  to  cut  off  the  circula- 
tion, would  result  in  gangrene  of  the  cyst,  hemorrhage,  peritonitis, 
sepsis,  and  suppuration,  and,  unless  relief  come  from  ovariotomv, 
death.  In  the  less  acute  cases  the  circulation  is  not  entirely  cut  oiff 
and  an  operation  if  delayed  will  be  more  difficult  on  account  of  ad- 
hesions.    Unless  ovariotomy  is  performed,  death  ordinarily  follows. 

Treatment. — The  only  treatment  of  both  acute  and  chronic  torsions 
is  immediate  ovariotomy. 

3.  Rupture  of  the  Cyst. 

The  cyst  may  rupture  into  the  abdominal  cavity,  or  into  some  one 
of  the  abdominal  viscera.  One  locument  of  a  multilocular  cyst  may 
rupture  into  another.  Thin- walled  secondary  compartments  very 
commonly  rupture  into  the  abdominal  cavity,  leaving  the  remaining 
compartments  of  the  cyst  intact.  The  opening  made  by  rupture  may 
reunite  and  the  cyst  refill. 


454  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS. 

Causes : 

1.  Softening  or  thinning  of  the  cyst-wall  in  one  or  more  places; 

this  may  occur  as  the  result  of  inflammation  or  distention. 

2.  Hemorrhage  into  the  cyst-wall  or  into  the  sac. 

3.  Fatty  degeneration,  necrosis,  or  gangrene  of  the  cyst-wall. 

4.  Suppuration  in  the  cyst. 

5.  Papillomatous  growths  penetrating  the  cyst-wall. 

G.  Direct  injury  from  blows,  falls,  careless  palpation  in  examina- 
tion, and  contraction  of  the  abdominal  wall  in  labor. 
7.  Torsion  ;  see  twisting  of  the  pedicle. 
Results. — A  ruptured   parovarian  cyst  may  in  exceptional  cases 
become  obliterated  and  thereby  spontaneously  cured.     Cases  of  sup- 
posed ovarian  cysts  have  been  reported  as  cured  by  rupture   or  tap- 
ping, but  it  is  known  that  an   ovarian   cyst  cannot  be   cured   in   this 
way ;   the  tumors  in  question  therefore  must  have  been  parovarian. 
The  former  practice  of  tapping  ovarian  cysts  as  a  means  of  radical 
cure  has  been  abandoned.     Even  parovarian  cysts  are  treated  better 
by  removal. 

Rupture  may  occur  into  : 

1.  Peritoneal  cavity,  most  frequent.     5.  Small  intestine,  rare. 

2.  Bladder.  6.  Stomach,  rare. 

3.  Vagina.  7.  Fallopian  tube,  rare. 

4.  Rectum.  •  8.   Abdominal  wall,  rare. 
Fate  of  escaped  contents  and  sequels  of  rupture  : 

1.  If  a  parovarian  or  an  ovarian  cyst  containing  innocent  aseptic 

fluid  ruptures  into  the  abdomen,  the  fluid  may  be  absorbed 
through  the  peritoneum  and  eliminated  by  the  kidneys 
without  harm. 

2.  If  rupture  of  a  papillomatous  cyst  takes  place  into  the  abdo- 

men, the  cyst  contents  are  liable  to  form  secondary  papil- 
lomata  on  the  peritoneum. 

3.  The  contents  of  a  dermoid  cyst  may,  if  septic,  infect  the 

peritoneum,  or  dermoid  elements  may  be  engrafted  on  the 
peritoneum. 

4.  The  colloid  contents  of  a  cyst  may  cause  peritonitis. 

5.  The  contents  from  a  malignant  cyst  may  engraft  malignant 

disease  on  the  peritoneum. 

6.  If  fluid  passes  by  rupture  into  a  hollow  viscus,  the  opening 

may  close  and  the  sac  refill,  or  the  opening  may  remain 
and  transmit  the  contents  of  the  viscus  to  the  sac ;  thus 
feces  and  gas  may  escape  from  the  bowel  to  the  tumor 
and  replace  the  tumor  dulness  with  resonance  on  percus- 
sion ;  or  urine  from  the  bladder  may  fill  the  sac. 
The  Symptoms,  Diagnosis,  and  Prognosis  of  rupture  will  vary 
according  to  the  condition  outlined  in  the  preceding  paragraphs.    The 
gravity  of  the  case  will  depend  upon  the  nature  of  the  escaped  fluid. 
The  accident  even   in  the  non-fatal  cases  is  apt  to  be  marked  by 
sudden  severe  pain,  and  by  more  or  less  severe  peritonitis  with  adhe^ 
sions.     A  monocyst  upon  discharge  of  its  contents  will  collapse.     A 
polycyst  upon  rupture  of  one  or  more  of  its  iocuments  only  changes 


SECONDARY  CHANGES.  455 

its  form.     Rupture  of  an  infected  cyst  into  the  peritoneum  is  usually 
fatal. 

Treatment. — The  greater  the  gravity  of  the  case  the  more  urgent 
the  indication — immediate  ovariotomy. 

SYMPTOMATOLOGY. 

The  symptoms  of  ovarian  and  parovarian  tumors,  of  which  none 
is  pathognomonic,  are : 

1.  Nutritive    disorders;   intestinal   indigestion,  and,   in    many 

cases,  constipation. 

2.  Menstrual  disturbances  ;  not  very  significant : 

a.  Uterine  hemorrhage  or  amenorrhoea. 
h.  Dysmenorrhoea. 

3.  Sterility ;  not  invariable,  even  in  bilateral  cases. 

4.  Pregnancy  may  be  simulated. 

5.  Pains  from  peritonitis  not  uncommon. 

6.  Pressure-symptoms : 

a.  Vesical  and  rectal  tenesmus. 

6.  CEdema  of  vagina,  vulva,  and  lower  extremities  from 
pressure  on  iliac  veins. 

c.  Abdominal  pains. 

d.  Uterine  displacements. 

e.  Hemorrhoids. 

/.  Urinary  functions  disturbed ;  albuminuria  associated 
with  pressure  on  renal  artery ;  suppression  of  urine 
and  hydronephrosis  from  pressure  on  ureters.  Vesical 
irritation  and  cystitis  from  pressure  on  bladder. 

g.  Ascites  from  pressure  on  vena  cava,  or  from  malig- 
nancy. 

h.  Pressure  on  thoracic  viscera  may  cause  most  distress- 
ing symptoms,  such  as  weakness  of  the  heart,  rapid 
pulse,  and  dyspnoea  so  extreme  that  the  ])atient  must 
maintain  continuously  the  sitting  posture,  night  and 
day ;  pressure  on  the  stomach  and  bowels  may  cause 
nausea,  vomiting,  and  other  alimentary  disturbances  ; 
pressure  on  the  liver  and  bile-ducts  may  cause 
catarrhal  jaundice. 

7.  Umbilical  hernia — occasional. 

8.  Atrophic  lines  on  abdominal  skin  when  cyst  is  large. 

9.  The  Facies  Ovariana.— This  is  a  peculiar  facial  expression 

that  is  somewhat  diagnostic  of  the  disease  in  the 
later  stages.  It  is  difficult  to  describe,  but  once 
seen  is  remembered  easily.  The  natural  facial  ex- 
pression is  modified  as  follows  : 

a.  The  face  is  shrivelled,  elongated,  and  has  an  anxious 
and  careworn  expression. 

h.  The  nostrils  are  wide,  the  angles  of  the  nose  and  mouth 
are  drawn  down,  and  the  lips  are  thin. 

c.  The  cheeks  are  furrowed  and  the  face  is  marked  by 
deep  wrinkles. 


456  TUMORS,    TUBAL  PREGNANCY,  MALFORMATIONS. 

d.  The  space  between  the  eyelids,  and  the  bony  margin 

of  the  orbits  is  sunken  and  hollow. 

e.  The  whole  areolar  tissue  of  the  face  is  atrophied. 

/.  The  face  is  pale,  but  not  with  that  peculiar  leaden, 

sallow,  or  parchment-like  color  seen  in  malignant 

diseases.^ 

The  fades  ovariana  is  quite  in  contrast  with  an  indescribable  and 

less  marked  facial  expression  known  as  the  fades  uterina.     This  is 

often  present  in  pregnancy  and  sometimes  in  cases  of  uterine  tumors. 

The  face  is  full  and  flushed. 

DIAGNOSIS. 

The  recognition  of  a  large,  uncomplicated  ovarian  cyst  is  usually 
not  difficult.     The  means  of  diagnosis  are  :^ 

1.  Clinical  history. 

2.  Inspection. 

3.  Palpation. 

4.  Percussion. 

5.  Conjoined  examination. 

6.  Measurement. 

7.  Aspiration  or  tapping. 

8.  Exploratory  incision. 

The  physical  examination  by  inspection,  palpation,  percussion, 
or  conjoined  manipulation  requires  that  the  abdomen  be  'exposed 
and  that  the  patient  lie  on  a  hard  couch  or  table,  preferably  the 
latter. 

1.  The  Clinical  History  should  include  a  consideration  of  the 
secondary  changes  as  outlined  in  this  chapter.  It  also  includes 
the  symptoms  noted  in  the  foregoing  paragraphs,  the  age,  social  con- 
dition, pregnancies  (if  any),  family  history,  and  menstrual  history  of 
the  patient. 

2.  Inspection. — If  the  tumor  is  small,  the  enlargement  will 
be  most  apparent  on  the  affected  side ;  as  it  grows  larger  and  rises 
out  of  the  pelvis  the  swelling  will  be  greater  in  the  lower  part  of 
the  abdomen  between  the  pubes  and  the  umbilicus,  and  will  be 
nearer  the  median  line.  Abdominal  enlargement  from  a  uni- 
locular cyst  is  obviously  more  symmetrical  than  from  a  multilocular 
cyst.  With  declining  strength  the  facies  ovariana  becomes  more 
pronounced. 

3.  Palpation  will  show  usually  a  fluctuating  tumor:  if  small,  in 
the  pelvis ;  if  large,  extending  into  the  abdomen.  The  mass  will  be 
much  more  distinct  on  the  affected  side.  The  degree  and  character 
of  elasticity  will  vary  with  the  tenseness  of  the  cyst  and  the  consist- 
ence of  the  contents.  A  greatly  distended  tense  sac,  especially  if  the 
contents  are  semisolid,  may  feel  like  a  solid  tumor. 

It   is   rare    to   find    solid    matter    predominating   in    an    ovarian 

1  Adaptation  from  Peaslee's  Ovarian  Tumors. 

-  In  tlae  diagnosis  and  differential  diagnosis  I  have  made  numerous  adaptations  from  the 
classical  work  on  ovarian  tumors  by  my  honored  friend  and  teacher,  the  late  Edmund  Ran- 
dolph Peaslee. 


SECONDARY  CHANGES.  457 

cyst.  Large  masses  of  semisolid  matter,  and  small  nodules  of 
very  hard  or  bone-like  substance,  often  are  detected  by  palpa- 
tion. The  more  solid  parts  are  found  rather  in  the  pelvis  than 
in  the  abdomen.  The  different  locuments  of  a  multilocular  cyst 
in  some  cases  are  outlined  easily  by  palpation.  The  cyst  sometimes 
may  be  moved  from  side  to  side,  and  up  and  down ;  the  degree  of 
mobility  will  depend  upon  its  size,  the  length  of  the  pedicle,  and  the 
extent  of  the  adhesions.  In  cases  of  very  thick  or  rigid  abdominal 
walls,  and  especially  of  small  tumors,  anaesthesia  facilitates  the 
examination. 

4.  Percussion. — The  tumor-sac,  with  its  contents,  occupies  the 
anterior  part  of  the  abdomen ;  the  intestines  are  in  the  posterior, 
lateral,  and  upper  parts ;  hence  the  maximum  dulness  on  percussion 
will  be  over  the  anterior  and  lower  portions  of  the  abdomen.  Since 
the  cyst  extends  from  the  pelvis,  the  dulness  will  be  continuous  from 
the  abdomen  into  the  pelvis  ;  it,  however,  will  cease  abruptly  or  shade 
off  into  resonance  and  tympanites  at  the  limits  of  the  tumor,  toward 
the  sides  of  the  abdomen  and  toward  the  diaphragm.  This  is  because 
the  spaces  above  and  to  the  sides  of  the  tumor  are  filled  with  intes- 
tine. For  the  relative  areas  of  dulness  and  resonance,  see  Differen- 
tial Diagnosis  of  Ovarian  Cyst  and  Ascites.  The  location  of  the 
cyst  does  not  change  with  change  in  the  position  of  the  patient ;  the 
areas  of  dulness  correspond  to  the  location  of  the  tumors,  and  are 
constant. 

The  Percussion  Wave  usually  present  is  elicited  by  placing  the 
finger-tips  of  the  left  hand  to  one  side  of  the  tumor,  and  with  the 
finger-tips  of  the  right  hand  sharply  tapping  or  thumping,  or  with  the 
thumb  and  finger  snapping  the  other  side.  In  very  tense  cysts  and 
in  cysts  with  semisolid  contents,  like  dermoids,  the  wave  may  be  slight 
or  absent. 

5.  Conjoined  Examination,  which  includes  vaginal  and  rectal 
touch,  will  show  usually  the  relations  of  the  uterus  to  tlie  cyst.  The 
importance  of  this  means  of  diagnosis  is  great,  for  any  cyst  of  pelvic 
origin  not  connected  with  the  uterus  is  almost  certainly  ovarian  or 
parovarian.  If  therefore,  upon  vaginal  or  rectal  touch,  the  uterus 
proves  to  be  healthy  and  normally  mobile,  with  little  or  no  increase 
in  length,  the  presumption  is  in  favor  of  an  ovarian  tumor ;  if,  upon 
conjoined  examination  with  one  or  two  fingers  of  the  left  hand  in  the 
vagina  or  rectum,  and  the  right  hand  over  the  abdomen,  the  uterus 
can  be  made  out  distinct  and  separate  from  the  cyst-tumor,  the  evi- 
dence of  ovarian  tumor  is  very  strong. 

In  very  exceptional  cases  of  ovarian  cyst,  however,  the  uterus  may 
be  enlarged,  drawn  up  out  of  the  true  pelvis,  immobile,  and  other- 
wise abnormal.  The  cyst  may  be  so  moulded  to  the  pelvis  as  to  press 
the  uterus  forward  and  upward  and  flatten  it  against  the  pubes. 
The  tumor  and  the  uterus  may,  through  adhesions  or  location,  be 
nearly  or  quite  inseparable  from  each  other ;  such  conditions  are  very 
indicative  of  uterine  tumors,  but  are  found  occasionally  witli  ovarian 
cysts.  See  Differential  Diagnosis  of  Ovarian  Cysts  and  Uterine 
Tumors. 

28 


458  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

6.  Measurements. — The  circular  measurement  of  the  abdomen  is 
increased.  The  distance  from  the  anterior  superior  process  of  the 
ilium  to  the  umbilicus  is  greater  on  the  affected  side.  The  distance 
from  the  pubes  to  the  umbilicus  is  increased  relatively  more  than  that 
from  the  umbilicus  to  the  ensiform  cartilage. 

7.  Aspiration,  or  Tapping,  once  a  common  means  of  diagnosis, 
is  now  almost  abandoned.  This  is  because  there  is  always  some 
danger  from  the  possible  escape  of  fluid  into  the  abdominal  cavity. 
The  diagnosis  usually  can  be  made  without  tapping,  and,  moreover, 
an  exploratory  incision  is  safer  and  more  effective. 

8.  Exploratory  Incision  is  the  final  resort  in  diagnosis  and  differ- 
ential diagnosis.  When  this  is  done  the  patient  should  be  prepared 
for  ovariotomy,  and  the  tumor,  if  operable,  should  be  removed. 

Diagnosis  of  Adhesions. 

Adhesions  may  be  recognized,  though  not  with  certainty,  by  the 
following  signs  : 

1.  Immobility  of  the  tumor. 

2.  Sensitiveness  on  pressure  (peritonitis),  not  reliable. 

3.  Bands  of  adhesions  sometimes  may  be  felt  through  the  vagina 

or  at  the  sides  of  the  tumor. 

Diagnosis  of  Malignancy. 

The  physical  signs  of  malignancy,  not  conclusive,  are  as  follows  : 

1.  Nodular,  hard  surface. 

2.  Ascites,  always  present  in  malignancy,  seldom  much  in  benign 

tumors. 

3.  Cachexia,  and  oedema  of  the  lower  extremities. 

4.  Metastasis. 

5.  Ra])id  increase  of  growth  and  involvement  of  surrounding 

structures. 

PROGNOSIS. 

The  prognosis,  without  operation,  of  ovarian  and  parovarian  tu- 
mors has  been  indicated  partially  under  Secondary  Changes  in  the 
first  part  of  this  chapter.  Multilocular  proliferating  cysts  and  pa]->il- 
loraatous  cysts,  if  not  removed,  usually  cause  death  in  about  three 
years.     The  causes  of  death  are  : 

1.  Exhaustion    due  to    interference   with   sleep,  nutrition,  and 

respiration. 

2.  Nephritis,  hydronephrosis,  uraemia,  cystitis,  pyelitis. 

3.  Peritonitis  and  intestinal  obstruction. 

4.  Suppuration  and  gangrene  of  cyst. 

5.  Rupture  of  cyst ;  hemorrhages  from  any  cause. 

6.  Impediment  to  labor. 

The  prognosis  with  ovariotomy  should  show  a  mortality  of  less 
than  6  per  cent. 


SECONDARY  CHANGES.  459 

DIFFERENTIAL  DIAGNOSIS. 

This  subject  involves:  first,  the  differential  diagnosis  of  ovarian  and 
parovarian  cysts  from  one  another ;  second,  the  differentiation  of  these 
cysts  from  other  conditions  with  which  they  have  been  confounded. 

Distinction  between  Ovarian  and  Parovarian  Cysts. 

This  distinction  has  been  given  under  pathological  anatomy  and 
secondary  changes.  The  following  tabular  statement,  however,  will 
emphasize  the  differential  points  : 


Ovarian  ajsts. 

1.  Develop  from  the  ovary. 

2.  UsuaUy  muUilocular. 

3.  Apt  to  contract  adhesions. 

4.  May  be  small  or  attain  enormous  size ; 


Parovarian  cysts. 

1.  Develop  from  the  parovarium. 

2.  Almost  always  unilocular. 

3.  Do  not  usually  contract  adhesions. 

4.  May  become  quite  large,  but  not  so  large 


growth  m.ore  rapid.  ^  as  ovarian  cysts  :  growth  slower. 


5.  Never  cured  by  tapping. 

6.  Fluid  may  be  thick,  thin,  muddy,  light, 
dark,  straw-  or  cofTee-colored,  albuminous. 

7.  Usually  pedunculated  unless  situated  be- 
tween folds  of  broad  ligament. 

8.  Sometimes  contains  warts— 1  e.,  papillo- 
mata. 

9.  Sac-wall  does  not  usually  have  peritoneal 
covering. 

10.  Apt  to  be  adenomatous  and  may  be  papil- 
lomatous. 

11.  Is  fatal  in  three  or  four  years.   Facies  ova- 
riana  marked. 


Sometimes  cured  by  tapping. 

6.  Fluid  usually  light,  like  spring  water. 
Specific  gravity  rarely  as  high  as  1010.  May  be 
only  slightly  albuminous  or  non-albuminous. 

7.  Usually  not  pedunculated.  Development 
apt  to  be  in  broad  ligament. 

8.  Seldom  papillomatous. 

9.  Sac  has  peritoneal  covering,  from  which 
it  may  be  readily  enucleated. 

10.  Is  neither  an  adenoma  nor  a  papilloma. 

11.  May  not  impair  health  for  many  years. 
Facies  ovariana  absent  or  not  marked. 


Dermoid  Tumors  develop  from  the  cortex  of  the  ovary,  and  are  a 
special  variety  of  ovarian  cysts.  They  have  been  described  specially 
in  a  preceding  chapter,  excepting  teratomata  (complicated  dermoids). 
The  diagnostic  points  by  which  dermoids  (simple)  may  be  distin- 
guished from  the  two  kinds  of  cysts  just  tabulated  are  these : 

1.  Facies  ovariana  comes  very  late,  if  at  all. 

3.  The  tumor  may  exist  for  many  years  without  impairment  of  the 
general  health. 

3.  Abdominal  enlargement  usually  to  one  side ;  is  otherwise  sym- 
metrical. 

4.  The  tumor  does  not  grow  to  very  large  size. 

5.  Contents  are  too  thick  to  permit  ta})ping  even  with  a  large  trocar. 

6.  Inflammation  of  cysts  and  adhesions  not  very  common. 

7.  Spontaneous  rupture  not  common. 

8.  (Edema  of  lower  extremities  rare. 

9.  Fluctuation  and  percussion  wave  obscure  or  absent. 

10.  Sac  contains  dermoid  element. 

Explanation  of  Figure  204. 
Ovarian  cysts  and  other  conditions  which  simulate  them. 

A,  ovarian  cyst  with  ascites;  the  ascites  causes  the  umbilicus  to  bulge. 

B,  ordinary  ovarian  cyst. 

C,  characteristic  shape  of  abdomen  in  nearly  symmetrical  myoma. 

D,  shape  of  abdomen  in  multiple  myoma  or  carcinoma. 

E,  cylindrical  shape  of  abdomen  in  ascites. 

F,  ascites  with  relaxed  abdominal  wall. 

G,  pendulous  abdomen  in  fat  woman. 

H,  pendulous  abdomen  from  advanced  ovarian  cyst ;  woman  much  emaciated. 


460  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


FlGUEE  204. 


SECONDARY  CHANGES. 


461 


11.  Location  of  small  dermoid  cysts  more  apt  to  be  anterior  than 
posterior  to  uterus. 

12.  May  occur  early  in  childhood. 

Complicated  teratomata,  as  explained  in  the  preceding  chapter,  have 
a  strong  malignant  tendency,  may  be  of  rapid  growth,  and  may  destroy 
life  in  a  short  time. 

The  Differentiation  of  Ovarian  Cysts  from  Other  Conditions  that 
may  be  Mistaken  for  Them. 

The  pathological  conditions  that  have  been  mistaken  f-r  ovarian 
cysts  may,  for  convenience  of  description,  be  divided  into  those  which 
originate  in  the  pelvis  and  those  which  originate  in  the  abdomen. 
Among  the  more  important  of  these  conditions  may  be  mentioned  the 
foUowino' : 


Intrapelvie  condition!),  vjhich  may  he  mistaken  for 
ovarian  cyst. 

Normal  gestation, 
Hydramnios, 
Pregnancy  ....•{  Tubal  pregnancy, 

Gestation    in   one    horn 
of  a  bifurcated  uterus. 


Myoma, 
Sarcoma, 
Carcinoma, 
Metritis, 
Hsematometra, 
Hydrometra, 
I  Pyometra, 
t  Physometra. 


Uterine  tumors , 


Inflammatory  en- 
largement   .  .   . 


(  Parametritis, 
I   Pelvic  abscess. 
■i  Sactosalpinx, 

Peritonitis, 
L  PericEecai  abscess. 


Abdominal  conditions,  which  may  be  mistaken  for 
ovarian  cyst. 
Ascites. 

Encysted  ascites. 
Hydatid  cysts. 
Renal  tumors. 
Floating  liiduey. 
Pancreatic  cy.st. 
Enlarged  liver. 
Mesenteric  cyst. 
Cysts  of  the  uraehus. 
Enlarged  gall-bladder. 
Intestinal  tumors. 
Fatty  tumors. 


One  or  more  of  the  above  conditions  may  coexist  with  ovarian 
cystoma.  The  diagnosis  then  is  complicated,  difficult,  and  M'ithout 
exploratory  incision  may  be  impossible.  Before  taking  up  the  sub- 
jects outlined  in  the  foregoing  table  it  is  important  to  consider  the 
following  question  : 

Question  I. — Is  there  any  tumor  at  all  within  the  peritoneal 
cavity  ? 

The  abdomen  has  been  opened  repeatedly  for  the  removal  of  a 
supposed  ovarian  tumor  when  no  tumor  of  any  kind  existed  ;  even 
more  frequently,  tapping  and  aspiration  have  been  done  when  no 
fluid  was  present.  One  author,  in  his  statistical  tables,  mentions 
no  less  than  twenty-one  cases  of  the  kind.^  The  following  conditions 
may  give  the  appearance  of  an  intra-abdominal  growth  when  no  such 
growth  exists  : 

1.  Fat  in  the  abdominal  walls. 

2.  Phantom  tumor. 

3.  Tympanites. 

4.  Fecal  accumulations. 

5.  Distended  bladder. 

6.  Dilated  stomach. 

1  John  Clary,  in  Ovarian  Tumors,  1872,  Peasleee. 


462  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

1.  Fat  in  the  Abdominal  Wall. — An  eminent  British  surgeon 
once  laid  open  the  abdomen  from  the  pubes  to  the  ensiform  cartilage, 
only  to  find,  instead  of  an  ovarian  cyst,  a  mass  of  subcutaneous  fat. 
Similar  blunders  have  occurred  repeatedly.  Such  an  error  at  the 
present  day,  however,  should  be  almost  impossible.  No  proper  signs 
of  ovarian  cyst  would  be  present  in  such  a  case.  The  mass  of  fat  in 
the  abdominal  wall  may  be  grasped  between  the  hands  and  isolated 
from  the  abdomen.  Vaginal  touch  would  also  yield  negative  evi- 
dence of  a  tumor.  Great  thickening  of  the  abdominal  wall  from 
oedema  is  differentiated  by  pitting  on  pressure. 

2.  Phantom  Tumor. — Some  hysterical  women  have  the  power  so 
to  contract  the  abdominal  muscles  as  to  force  up  the  tympanitic  intes- 
tines into  a  bunch,  and  in  this  way  to  make  an  apparent  abdominal 
enlargement  in  form  like  that  of  a  tumor.  Prolonged  firm  pressure 
with  the  palms  of  the  hands  usually  overcomes  the  muscular  contrac- 
tion. The  percussion  note  is  decidedly  tympanitic.  Anaesthesia 
completely  exposes  the  deception. 

3.  Tympanites. — The  extraordinary  blunder  occasionally  has 
been  made  of  mistaking  tympanites  for  an  abdominal  tumor.  This 
has  occurred  usually  when  the  evidences  of  percussion  and  palpation 
were  obscured  by  large  amounts  of  abdominal  fat.  Tympanites  will 
be  known  by  resonance  on  percussion,  absence  of  the  percussion  wave, 
and  by  the  negative  results  of  vaginal  touch. 

4.  Fecal  Accumulations  in  the  bowel  have  led  occasionally  to  the 
suspicion  of  an  ovarian  cyst.  The  history  of  constipation,  supple- 
mented by  palpation,  will  settle  the  diagnosis  ;  if  not,  active  catharsis 
will  remove  all  doubt.  Deep  pressure  through  a  thin  abdominal  wall 
or  through  the  vagina  causes  pitting  of  the  distended  bowel. 

5.  Distended  Bladder. — Retained  urine  may  accumulate  in  large 
quantity  until  the  bladder  appears  between  the  pubes  and  umbilicus 
as  a  distinct  fluctuating  tumor.  The  external  appearance,  on  inspec- 
tion, palpation,  and  percussion,  is  very  like  ovarian  cystoma.  The 
anterior  vaginal  wall,  however,  bulges  into  the  vulvar  orifice.  There 
is  an  almost  or  quite  continuous  overflow  of  urine  through  the  urethra. 
Hypogastric  pain  and  distress  are  urgent.  The  use  of  the  catheter 
will  settle  all  possible  doubt. 

6.  Dilated  Stomach. — The  author  personally  knows  of  one  case  in 
which  a  deservedly  eminent  surgeon  opened  the  abdomen  for  a  sup- 
posed ovarian  cyst,  and  found  instead  a  dilated  stomach.  The  condi- 
tion ordinarily  would  be  distinguished  from  cyst  by  the  maximum  en- 
largement above  instead  of  below  the  umbilicus,  and  by  resonance  on 
percussion  all  over  the  tumor.  A  positive  test  is  to  let  the  patient 
swallow  water  while  the  stethoscope  is  placed  over  the  tumor.  As  the 
water  reaches  the  stomach  a  gurgling  sound  will  be  heard  clearly  all 
over  the  enlargement.  Inflation  of  the  stomach  through  a  tube 
would  cause  a  decided  tympanitic  note  over  the  abdomen. 

Given  sufficient  evidence  that  there  is  a  tumor,  the  next  inquiry 
is — 

Question  II. :  Is  the  enlargement  of  pelvic  or  of  abdominal 
origin  ? 


SECONDARY  CHANGES. 


463 


If  not  of  pelvic  origin,  it  cannot  be  ovarian,  and  therefore  does  not 
come  within  the  scope  of  this  inquiry.  If  the  hand  cannot  be  inserted 
by  deep  firm  pressure  between  the  tumor  and  the  symphysis  pubis,  it 
is  inferred  that  the  tumor  rises  from  the  pelvis  ;  if  vaginal  and 
rectal  touch  confirm  this  inference,  it  is  so  decided/  The  pelvic 
origin  of  the  tumor  being  established,  the  next  inquiry  is — 

QuESTioisr  III.:     Is  the  tumor  possibly  due  to  pregnancy  ? 

The  humiliation  of  attempting  to  remove  from  a  pregnant  woman  an 
ovarian  tumor  which  does  not  exist  may  be  avoided  by  assuming,  until 
the  contrary  is  proved,  that  every  abdominal  enlargement  in  a  woman  is 
due  to  pregnaney. 


Differential  Diagnosis  of  Normal  Gestation  and   Ovarian  Cyst. 


Normal  gestation. 

1.  Enlargement  sudden,  rapid,  and  usually 
symmetrical. 

2.  Facies  natural  and  healthy. 

3.  Superficial  veins  of  abdomen  not  en- 
larged. Oedema  of  ankles  not  uncommon  after 
seven  months. 

4.  Fluctuation  not  distinct  unless  liquor 
amnii  is  excessive. 

5.  Menstruation  arrested. 

6.  Vaginal  touch  detects  softening  and  ap- 
parent shortening  of  the  cervix  and  enlarge- 
ment of  the  uterus.    No  extra-uterine  tumor. 

7.  Ballottement  gives  impulse  of  fcetus. 

8.  Fcetal  heart-sounds  after  twentieth  week. 

9.  Foetal  movements  about  sixteenth  week. 

10.  Enlarged  sebaceous  glands ;  areola  about 
nipples  darkened. 

11.  Tumor   has   develoned    in   six   to   nine 
months. 


Ovarian  cyst. 

1.  Enlargement  gradual  and,  until  tumor 
becomes  large,  asymmetrical. 

2.  Facies  ovariana  in  later  stages. 

3.  Veins  enlarged.  QSdema  exceptional  and 
only  alter  one  or  two  years. 

4  Usually  very  distinct,  especially  in  mono- 
cysts. 

5.  Not  usually  arrested  unless  late  in  the 
disease. 

6.  Uterus  unchanged  except  by  displace- 
ment, usually  in  front  of  or  behind  the  cyst. 
Tumor  extra-uterine. 

7.  Ballottement  gives  negative  results. 

8.  None. 

9.  None. 

10.  Rarely  imitated. 

11.  Development  continues  two  to  four  years. 


If  the  foetus  is  dead,  the  heart-sounds  and  foetal  movements  will, 
of  course,  not  be  present. 

Ovarian  cyst  and  pregnancy  not  infrequently  coexist.  The  diag- 
nosis then  is  made  by  the  clinical  history  of  both  conditions,  by  palpa- 
tion, and  by  conjoined  examination. 

Hydramnios  is  an  excess  of  amniotic  fluid.  There  are  normally 
from  six  to  thirty  ounces ;  this  amount  may  be  increased  enormously, 
giving  the  uterus  the  appearance  of  an  immense  cyst.  The  attempt 
has  been  made  occasionally  to  tap  or  remove  such  a  tumor  by  mistake 
for  an  ovarian  cyst. 

The  differential  diagnosis  of  hydramnios  and  ovarian  cyst  is  as 
follows  : 


Hydramnios. 

1.  Evidence  of  pregnancy. 

2.  Rapid  development. 

3.  Ballottement. 

4.  Distention  symmetrical. 


Ovarian  cyst. 

1.  Not  usual. 

2.  Less  rapid. 

3.  Absent. 

i.  Distention  more  on  one  side. 


Tubal  Pregnancy.— The  diagnosis  of  this  condition  will  be  found 
in  Chapter  XXXVT.  Unlike  ovarian  cyst,  it  gives  an  early, 
though  irregular,  history,  as  of  pregnancy.  Conjoined  examination 
before  rupture  shows  a  boggy,  fluctuating,  pulsating  tumor  at  the  side 
and  back  of  the  uterus.     After  rupture  the  tumor  is  less  distinct,  non- 

1  Adaptation  from  Peaslee's  Ovarian  Tumors. 


aihid. 


464 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


pulsating,  and  non-fluctuating.  At  or  near  the  time  of  rupture  the 
endometrium  throws  oif  a  modified  decidua  of  pregnancy.  The 
symptoms  of  rupture  are  urgent ;  they  are  those  of  pelvic  hsematocele, 
and  are  not  likely  to  be  mistaken  for  any  symptoms  of  ovarian  cysl 
unless  it  be  those  of  rupture  of  the  sac  or  twisting  of  the  pedicle. 

Gestation  in  One  Horn  of  a  Bifurcated  Uterus. — The  unilateral 
location  may  give  bicornate  pregnancy  the  appearance  of  an  ovarian 
cyst  or  of  a  myoma. 

Question  IV.  :  Is  there  a  uterine  enlargement  due  to  other 
causes  than  pregnancy? 

The  pathological  conditions  suggested  by  the  question  are  these : 

Uterine  myoma.  Haematometra. 

Uterine  sarcoma.  Hydrometra. 

Uterine  carcinoma.  Pyometra. 

Metritis.  Physometra. 


Differentiation  of  Uterine  Myoma  from  Ovarian  Cystoma.' 


uterine  myoma. 

1.  Slow  growth. 

2.  Facial  expression  unchanged.  Face  may 
be  full  and  flushed;  later  pale  from  hemor- 
rhage. 

3.  General  health  not  necessarily  impaired 
except  from  loss  of  blood  If  submucous  or 
mural ;  may  be  painful. 

4.  Abdomen  often  asymmetrical  from  irreg- 
ular shape  of  tumor. 

5.  Abdominal  veins  not  usually  enlarged. 

6.  Action  of  kidneys  normal. 

7.  Usual  menorrhagia. 

8.  Elasticity,  not  fluctuation.  No  percus- 
sion-wave. 

9.  Surface  firm  and  usually  lobulated. 

10.  Vaginal  touch  and  conjoined  examina- 
tion show  tumor  dense  and  firm,  and,  unless 
pedunculated,  continuous  with  uterus.  Uterus 
large  and  heavy. 

11.  Uterine  cavity  much  elongated. 

12.  Uterus  moves  with  tumor. 

13.  Negative  results  from  aspiration ;  aspira- 
tion not  advised. 

Exceptions.— X  subperitoneal  myoma  with  a 
long  pedicle  moves  independently  of  the 
uterus,  and  the  uterine  cavity  is  not  neces- 
sarily lengthened.  If  the  myoma  has  degen- 
erated to  a  flbrocyst,  there  will  be  more  or  less 
fluctuation,  and  aspiration  may  yield  positive 
results. 


Ovarian  cystoma. 

1.  Usually  more  rapid  growth. 

2.  Facies  ovariana  in  later  stages. 


3.  General  health  early  impaired  from  ema- 
ciation.   Not  painful. 

4.  Abdomen  more  symmetrical,  especially 
when  tumor  is  large. 

5.  Usually  enlarged,  especially  in  large 
polycysts. 

6.  Kidneys  less  active. 

7.  Menstruation  unchanged  or  diminished. 

8.  Fluctuation  marked.  Percussion-wave 
marked. 

9.  Surface  yielding ;  in  monocysts,  regular ; 
in  polycysts,  irregular. 

lu.  Uterus  normal,  except  displacement  from 
pressure.  Tumor  compressible,  fluctuating, 
separate  from  uterus. 

11.  Not  materially  elongated.  (This  is  a  most 
important  diagnostic  j)oint.) 

12.  Does  not  move  with  tumor. 

13.  Positive  results  from  aspiration  (aspira- 
tion not  advised). 

Exception.— X  cyst  with  semisolid  contents 
yields  negative  results  on  aspiratio'n.  Fluctua- 
tion, if  present,  is  indistinct,  and  percussion- 
wave  is  absent  or  indefinite. 


GEdematous  myoma  may  give  rise  to  an  apparent  fluctuation — 
pseudofluctuation. 


Differentiation  of  Uterine  Sarcoma  and  Carcinoma  from 
Ovarian  Cyst. 

The  relations  of  these  growths  to  the  uterus  are  similar  to  those  of 
myoma.  The  accompanying  tabulated  statement  concerning  myoma, 
therefore,  in  the  main  applies  to  malignant  growths.  Malignant 
uterine  tumors  differ  from   myoma  in  these  particulars — viz.,  more 

1  Adaptation  from  Peaslee's  Ovarian  Tumors. 


SECONDARY  CHANGES.  465 

pain,  great  tendency  to  early  ulceration  and  other  degenerative 
changes,  more  profuse  hemorrhages,  offensive  watery  or  bloody  dis- 
charge, cachexia,  and  a  speedily  fatal  result. 

Differentiation  of  Metritis  from  Ovarian  Cyst. 

Metritis  gives  a  history  of  inflammation,  and  is  apt  to  be  asso- 
ciated with  parametritis,  salpingitis,  and  ovaritis.  The  uterus  is 
never  enlarged  to  more  than  two  or  three  times  its  normal  size,  and 
in  form  is  always  symmetrical.  Conjoined  examination  will  show 
that  there  is  no  extra-uterine  growth.  There  are  also  tenderness  on 
pressure  and  diminished  mobility. 

Differentiation   of  Haematometra,   Hydrometra,  Pyometra,  and 
Physometra   from  Ovarian  Cyst. 

In  the  conditions  above  named  the  uterine  enlargement  is  always 
symmetrical,  and  the  uterus  whether  distended  with  blood,  serum, 
pus,  or  gas,  gives  a  greater  or  lesser  sense  of  fluctuation,  but  not  the 
clear  fluctuation  of  a  cyst.  See  Retained  Menstruation,  Chapter 
XXXVIII.  Examination  will  show  that  the  os  externum  or  the 
cervical  canal  at  some  point  is  closed  completely.  Unless  the  Fallo- 
pian tubes  also  are  distended  the  enlargement  will  be  confined  entirely 
to  the  uterus. 

Question  V.  :  Is  the  enlargement  extra-uterine,  and  possibly 
due  to  inflammation  ? 

This  question  suggests  the  following  conditions  : 

Parametritis,  Pyosalpinx,  Peritonitis, 

Pelvic  abscess.  Hydrosalpinx,  Pericsecal  abscess. 

The  history  of  inflammation  and  the  close  relations  of  the  enlarge- 
ment to  the  uterus  will  aid  greatly  in  the  recognition  of  any  of  these 
diseases.  In  all,  except  possibly  hydrosalpinx,  there  will  be  tender- 
ness on  pressure.  Sactosalpinx,  whether  the  tube  be  distended  with 
serum,  pus,  or  blood,  will  be  identified  usually  by  its  location  to  the 
side  and  back  of  the  uterus,  but  more  especially  by  the  irregular, 
elongated,  tortuous,  or  ovoid  form  of  the  mass.  A  pus-tube  is  much 
more  likely  to  be  adherent  than  an  ovarian  cyst  of  small  size.  A 
parametric  abscess  situated  in  the  broad  ligament  is  always  continu- 
ous with  the  side  of  the  uterus.  Suppuration,  anterior  or  posterior 
to  the  uterus,  is  also  inseparable  from  the  uterus,  Pericsecal  abscess 
or  appendicitis  may  be  suspected  from  its  location. 

Question  VI. :  Is  the  tumor  of  abdominal  origin,  and  therefore 
not  ovarian  ? 

A  large  ovarian  cyst  may  have  a  pedicle  so  long  as  to  permit  the 
entire  tumor  to  rise  out  of  the  pelvis  into  the  abdominal  cavity.  It 
may  even  be  possible  to  insert  the  hand  deeply  between  the  tumor 
and  the  symphysis  ]iubis.  Conjoined  vaginal  and  rectal  touch  may 
not  discover  the  pedicle,  nor  establish  the  pelvic  origin  of  the  cyst; 
it  is  sometimes  diflieult  to  diiferentiate  such  a  cyst  from  other  tumors 
of  abdominal  orifjin. 


466 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


The  following  extrapelvic  pathological  conditions  have  been  mis- 
taken for  ovarian  cyst : 


Ordinary  ascites. 

Encysted  ascites. 

Hydatid  cysts. 

Renal  cysts. 

Displaced  or  floating  kidney. 

Pancreatic  cyst. 


Enlarged  liver. 
Mesenteric  cyst. 
Cysts  of  the  urachns. 
Enlarged  gall-bladder. 
Intestinal  tumors. 
Fatty  tumors. 


Differential  Diagnosis  of  Ascites  and  Large  Ovarian  Cyst.^ 

Figure  205.  Figube  206. 


Fiot'RE  205. — .Areas  of  dnlness  and  resonance  in  ovarian  cyst;  dulness  over  tumor;  reso- 
nance over  intestine  in  the  flanli  opposite  to  tlie  side  on  whicli  the  tumor  has  developed.  There 
wonld  be  no  change  in  areas  of  resonance  and  dulness  with  change  in  position  of  patient;  dul- 
ness over  liver  in  hepatic  region. 

Figure  206. — Areas  of  resonance  and  dulness  in  ascites ;  resonance  over  intestines  ;  hydro- 
static dulness  below  level  of  fluid  in  the  flanks  :  dulness  over  liver  in  hepatic  region.  Con- 
stant change  in  areas  of  dulness  and  resonance  with  change  in  position  of  patient,  because 
Intestines  seek  high  level  and  fluid  seeks  low  level. 


Ascites. 

1.  Previous  history  of  visceral  disease. 

2.  Enlargement  comparatively  sudden. 

3.  Face  puffy ;  color  wa.xy  ;  early  anaemia. 

4.  Patient  on  back,  enlargement  symmetri- 
cal ;  flat  in  front. 

5.  Sitting  up,  abdomen  bulges  below. 

6.  Navel  prominent  and  thinned. 

7.  Fluctuation  decidedly  clear,  diffuse 
throughout  abdomen,  but  avoids  highest  parts 
in  all  positions,  and  always  has  a  hydrostatic 
level. 

8  Intestines  float  on  top  of  fluid ;  hence  per- 
cussion gives  clear  tympanitic  note  over  the 
highest  parts  of  abdominal  cavity,  and  dulness 
in  lowest  parts  for  all  positions-^i.  e.,  areas  of 
resonance  and  dnlness  change  with  position. 

9.  Vaginal  touch  detects  fluctuation,  bulging 
into  vagina. 


Ovarian  cyst. 

1.  No  such  history. 

2.  Gradual. 

3.  Facies  ovariana.    Ana?mia  absent  or  less 
marked  until  later  period. 

4.  Asymmetrical  until  tumor  is  quite  large; 
prominent  in  front. 

5.  No  apyjreciable  change. 

6.  Navel  usually  unchanged. 

7.  Less  clear ;  limited  to  cyst ;  not  modified 
by  change  of  position.    No  hydrostatic  level. 


8.  No  change  in  areas  of  dulness  and  reso- 
nance with  change  of  position.  Dulness  over 
cyst.  Clear  resonant  note  in  all  parts  beyond 
cyst  limits— «'.  e.,  in  flanks  and  toward  the 
diaphragm. 

9.  Vaginal  fluctuation  less  clear  or  absent. 


» Adaptation  from  Peaslee's  Ovarian  Tumors. 


SECONDARY  CHANGES. 


467 


Ascites. 

10.  Uterus  in  prolapsed  location.  Size  and 
mobility  unchanged. 

11.  Hydragogues  and  diuretics  temporarily 
remove  the  fluid. 

12.  Fluid  light  straw  color  and  thin.  Coagu- 
lates spontaneously. 

Exceptions.— The  intestines  may  be  adherent 
to  the  posterior  part  of  the  abdominal  cavity, 
and  the  fluid  may  therefore  be  in  the  anterior 
part,  or  the  amount  of  fluid  may  be  so  great  that 
the  intestines  held  back  by  mesentery  or  adhe- 
sion cannot  float  to  the  surface  ;  then  the  areas 
of  resonance  and  dulness,  except  on  very  deep 
percussion,  may  be  similar  to  those  of  a  cyst. 

Gas  in  the  colon  may  produce  clearness  in 
the  flanks. 

Encysted  ascites— J.  e.,  fluid  confined  to  a 
limited  part  of  the  abdomen  by  adhesions— may 
give  the  same  areas  of  dulness  and  resonance 
as  a  cyst. 


Ovarian  cyst. 

10.  Uterus  displaced  forward  or  backward,  o? 
laterally  by  pressure  of  cyst. 

11.  Medicines  have  no  effect. 

12.  Fluid  light  or  dark  and  of  varying  con- 
sistence; albuminous,  but  does  not  coagulate 
spontaneously  ;  may  contain  colloid  matter. 

Exceptions. — Flanks  may  be  dull  from  feces  in 
the  colon. 


Cyst  may  communicate  with  the  intestines 
and  be  filled  with  gas.  Tliis  would  give  a 
tympanitic  note  all  over  the  cyst. 

The  cyst  may  be  small  and  glued  to  the  pos- 
terior part  of  the  abdominal  cavity  by  adhe- 
sions. The  intestine  might  then  be  in  front  of 
it  and  give  a  tympanitic  note  over  the  most 
prominent  part  of  the  enlargement. 


Ovarian  cyst  and  ascites  may  coexist.  If  the  cyst  be  small  and 
the  patient  a  stout  woman,  the  diagnosis  without  exploratory  incision 
may  then  be  most  difficult. 

Differentiation  of  Hydatid  Cysts  from  Ovarian  Cysts. 

Hydatid,  or  echinococcus,  cysts  are  sometimes  difficult  to  distinguish 
from  ovarian  tumors.  They  may  originate  either  in  the  pelvis  or  in 
the  abdomen.  Hydatid  cysts  of  pelvic  origin  may  be  in  the  broad 
ligament  or  immediately  beneath  the  uterine  or  pelvic  peritoneum. 
Hydatid  abdominal  cysts  may  originate  in  the  omentum  or  liver.  If 
of  abdominal  origin  and  of  small  size,  their  location  usually  will  prove 
them  to  be  extrapelvic,  and  therefore  not  ovarian.  The  qualifying 
word  "usually"  is  introduced  because  the  writer  once  encountered  a 
small  ovarian  cyst  adherent  to  the  liver.  The  pedicle  was  in  this 
case  very  slender  and  about  seven  inches  long.  In  palpation  of 
hydatid  cysts  a  peculiar  fremitus  sometimes  is  imparted  to  the  fingers. 

Large  abdominal  hydatid  cysts  may  extend  into  the  pelvis,  and, 
like  those  of  pelvic  origin,  closely  simulate  ovarian  disease.  These 
cysts  unless  inflamed  are  rarely  painful.  When  they  distend  the 
abdomen,  they  project  as  a  mass  of  small,  rounded,  tense,  elastic 
bodies ;  the  indvidual  projections  are  smaller  than  those  of  ovarian 
cysts.  Fluctuation  is  distinct.  Suppuration  will  give  rise  to  signs 
of  an  abscess  in  addition  to  the  signs  of  hydatids. 

Definite  diagnosis  is  impossible  without  exploratory  incision.  The 
fluid  usually  will  show  the  characteristic  booklets.  It  is  sliglitly  alkaline 
or  neutral,  non-albuminous,  has  a  specific  gravity  of  about  iOlO,  and 
contains  chloride  of  sodium.  Fragments  of  the  characteristic  lami- 
nated lining  of  the  cyst  may  come  away  through  an  aspirator  or  trocar.^ 

Degenerative  processes  may  cause  rupture  of  tiie  cyst  and  dis- 
charge of  its  characteristic  vesicles,  booklets,  or  membranes  through 
the  vagina,  rectum,  or  bladder ;  the  diagnosis  is  then  clear.  Hydatid 
cysts  are  rare. 


1  Sutton.    Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes. 


468 


TUMORS,    TUBAL   PREGNANCY,   MALFORMATIONS. 


Differentiation  of  Renal  Tumors  and  Ovarian  Cysts. 

The  distinction  between  renal  tumors  and  other  abdominal  and 
pelvic  enlargements  is  often  extremely  difficult.  They  have  been 
repeatedly  mistaken,  not  only  for  ovarian  tumors,  but  as  well  for 
tumors  of  the  pancreas,  liver,  spleen,  intestine,  omentum,  and  uterus. 
Without  an  exploratory  incision,  the  greatest  care  and  the  widest 
general  knowledge  may  be  inadequate  to  a  diagnosis.  The  enlarged 
kidney  has  been  found,  not  only  so  loose  as  to  occupy  almost  any 
location  or  position  in  the  abdomen  or  pelvis,  but  fixed  by  adhesions 
in  its  mal-location — for  example,  to  the  pelvic  brim  or  to  the  sacrum. 

Figure  207. 


Left  kidney  in  the  hollow  of  the  sacrum  ;  the  renal  artery  and  vein  are  dragged  down  with 
the  kidney  producing  a  mechanical  disturbance  in  the  urinary  system  and  in  the  circulation 
which  would  necessarily  have  serious  results 

In  such  cases  the  clinical  history  and  rational  signs — including 
urinalysis — usually  will  give  evidence  of  renal  disease.  A  renal  cyst 
may  be  hydronephrosis  or  pyelonephrosis.  The  differentiation  is 
made  as  follows  : 


Hydronephrosis. 

1.  Enlargement  unilateral  and  from  above 
downward.    Growth  fixed  in  region  of  kidney. 

2.  Expression  unchanged. 

3.  Growth  usually  slow. 

4.  Intestines  may  be  in  front  of  tumor. 


Ovarian  cysts. 

1.  Enlargement  at  first  unilateral :  later  sym- 
metrical and  from  below  upward.  No  fixation. 

2.  Facies  ovariana. 

?,.  Growth  relatively  rapid. 
4.  Intestines  in  the  "flanks  above  and  back  of 
tumor. 


SECONDARY  CHANGES. 


460 


Hydronephrosis. 

5.  Fluid  not  necessarily  albuminous ;    may 
contain  calculi. 

6.  Vaginal  touch  negative. 

7.  Urine  may  contain  pus,  blood,  or  albumin. 

8.  Cy.stoscopy  shows  absence  of  urine  through 
ureter  on  afifected  side. 

Exception.— In  case  of  a  movable  kidney  the 
tumor  may  not  be  fixed. 


Ovarian  cysts. 

5.  Fluid  albuminous :  no  calculi. 

6.  Tumor  usually  felt  by  vaginal  touch, 

7.  Urine  generally  normal. 

8.  Urine  flows  through  ureter  on  both  sides. 

Exceptimi.—lii   case    of  adhesions   the   cyst 
may  be  fixed. 


In  pyelonephrosis  the  symptoms  of  suppuration  will  be  present. 

Pancreatic  oyst,  enlarged  liver,  mesenteric  cyst,  cyst  of  the  urachus, 
enlarged  gall-bladder,  intestinal  tumors,  subperitoneal  or  omental 
fatty  tumors,  all  of  which  may  grow  to  large  size,  have  been  mis- 
taken for  ovarian  cysts.  With  ordinary  care  and  skill,  however, 
such  mistakes  are  not  very  likely  to  arise.  All  these  tumors  develop 
from  above  downward,  and  may  be  distinguished  easily  from  ovarian 
cyst  by  their  location  and  physical  characteristics.  Unlike  ovarian 
cyst,  they  are  usually  beyond  the  reach  of  vaginal  touch. 


EXPLORATORY   INCISION. 

Finally,  in  cases  of  doubt,  the  question  may  be  settled  by  explora- 
tory incision.  Indeed,  every  ovariotomy — yes,  every  abdominal  sec- 
tion— should  begin  as  an  exploratory  incision.  Mr.  Tait's  wise 
caution,  already  quoted  in  connection  with  the  diagnosis  of  pelvic 
inflammation,  will  bear  repetition  here  :  "  One  may  easily  turn  an 
exploratory  incision  into  a  complete  operation,  but  it  may  be  a  serious 
matter  to  turn  an  incomplete  operation  into  an  exploratory  incision." 


CHAPTER   XXXIV. 

OVARIOTOMY. 

The  general  principles  which  apply  to  ovariotomy  are  laid  down 
in  Chapters  III.,  VI.,  VII.,  VIII. 

Electricity,  incision,  and  drainage,  and  numerous  drugs  have  been 
tried  in  the  treatment  of  ovarian  cysts  ;  they  are  all  useless.  The 
treatment  is  summed  up  in  a  single  word — ovariotomy.  The  opera- 
tion was  performed  first  in  1809  by  Ephraim  McDowell,  of 
Danville,  Ky. 

Removal  of  Ovarian  Cyst. 

The  subdivisions  of  the  subject  are  these : 
Preparatory  treatment. 
The  abdominal  incision. 
Emptying  and  delivering  the  cyst. 
Ligature  of  the  pedicle. 
Closure  of  the  wound. 
Drainage. 
After-treatment. 
Accidents  and  complications. 
The  Preparatory  Treatment  and  arrangements  for  the  operation, 
including  the  selection  of  sponges,   ordinary   instruments,  operating- 
table,  and  assistants,  have  been  outlined  in  the  General  Discussion  of 
Major  Operations,  Chapters  II.  and  VI.     The  instruments  and  appli- 
ances specially  required  are  : 

16  Small  pressure-forceps.     Figure  42,  a,  b,  e. 
6  Long  pressure-forceps.     Figure  6"],  A. 
2  Nekton  forceps.     Figure  208,  E. 

1  Scalpel. 

2  Pairs  of  straight  scissors. 

1  Ovariotomy  trocar.     Figure  208,  A. 
12  Needles,    round   at   the  point,    for   intraperitoneal    plastic 
work.     Figure  42. 
1  Pubber  sheet. 

1  Bucket  to  catch  the  cyst-fluid. 
1  Small,  curved  trocar.     Figure  208,  D. 
4  Petractors.     Figure  208,  B  and  C. 
The  Abdominal  Incision. — Ovariotomy,  except  for  small,  non- 
adherent  cysts,  is  performed  by  abdominal    section.     The    incision, 
made  through  the  abdominal  wall  in  the  median  line  near  the  pubes, 
has  been  described   in   Chapter  VI.     Vaginal  Section,   usually  not 
advised,  but  sometimes  used  for  very  small    cysts,  is  described    in 
Chapter  XXIII.     Ordinary,  uncomplicated  ovariotomy  requires  an 
incision  not  more  than  two  or  three  inches  long. 

Cyst  fluid  may  be   perfectly  innocent,  or,  on  the  contrary,  may, 
from    suppuration  or  other  causes,  contain   infectious  matter.     The 

470 


OVARIOTOMY. 

Fjgxjeb  208. 


471 


A, ovariotomy  trocar;  B,  retractor  for  keeping  abdominal  wound  open  during  the  operation 
(two  of  tliem  are  required) ;  C,  retractor  for  abdominal  wound ;  D,  small  trocar  for  emptying 
small  cysts ;  E,  N61aton's  cyst-forceps  for  drawing  out  the  empty  and  collapsed  cyst 


EXPLAXATION    OF    FiGURE   209. 

OVARIOTOMY. 

A.  Examining  the  Tumor.— The  abdomen  having  been  opened  by  an  incisicxi 
in  the  median  line,  the  liand  is  introduced  into  the  peritoneal  cavity  in  order  to  deter- 
mine the  presence  or  absence  of  adhesions,  and  to  break  up  any  slight  adhesions  which 
may  be  found. 

B.  Tapping  ttie  Cyst. — The  patient  is  on  the  right  side.  A  folded,  flat  gauze 
sponge  is  partially  introduced  into  the  peritoneal  cavity  and  held  by  the  left  hand  of 
the  operator,  in  order  to  absorb  any  fluid  which  may  escape  from  the  cyst.  The  oper- 
ator, with  his  right  hand,  plunges  the  trocar  into  the  cyst.  The  fluid  is  evacuated 
through  the  trocar  and  the  attached  rubber  tube  into  the  bucket  below. 

472 


Figure  209 


473 


Figure  210 


474 


Explanation  of  Figure  210. 

A.  As  the  Huid  passes  from  the  cyst  through  the  trocar  and  the  sac  begins  to  col- 
lapse, the  trocar  is  placed  in  the  hands  of  an  assistant,  and  the  operator  with  a  heavy 
long  forceps  in  each  hand  seizes  the  sac  on  either  side  of  the  trocar  at  points  a  and  6, 
and  makes  steady  traction,  so  that,  as  the  sac  is  emptied  and  collapsed,  it  may  be  drawn 
out  through  the  abdominal  incision.  During  the  emptying  of  the  sac  it  is  seized  suc- 
cessively at  different  points  by  first  one  forceps  and  then  the  other  until  it  is  delivered. 
The  delivery  of  the  sac  in  this  manner  by  traction  usually  would  be  rendered  imprac- 
ticable or  impossible  by  adhesions ;  see  .i.  Figure  211. 

B.  The  sac  has  been  emptied  or  nearly  emptied.     The  wound  in  the  sac-wall  made 

by  the  trocar  is  closed  temporarily  by  the  Nelaton  sac  forceps  e.     Forceps  a  and  b,  by 

which  the  sac  has  been  drawn  through   the  abdominal  incision,  are  hanging  upon  the 

cyst-wall.     The  pedicle  is  clamped  by  two  strong  forceps,  e  and  d,  which  then  are 

placed  in  the  hands  of  the  assistant,  and  the  pedicle  is  divided  between  them  by  means 

of  scissors  in  the  right  hand  of  the  operator,  while  his  left  hand  holds  the   tumor 

steady. 

475 


Figure  211 


476 


Explanation  of  Figure  211. 

A.  If  the  sac  is  adherent  to  adjacent  structures,  the  adhesions  must  be  broken  up 
before  it  can  be  delivered  through  the  abdominal  wound. 

Here  adhesions  are  shown  between  the  sac  and  the  intestine,  and  are  being  broken 
up  by  strong  pressure  with  the  sponge  in  the  right  hand  of  the  operator  while  his  left 
hand  holds  the  sac.  Very  extensive  and  firm  adhesions  may  be  separated— sponged 
offi  as  it  were — in  this  way. 

£.  The  sac  has  been  delivered  through  the  abdominal  incision,  the  pedicle  clamped, 
and  the  tumor  removed.  Here  the  pedicle  is  shown  temporarily  clamped  by  a  strong 
forceps.  This  forceps  corresponds  to  forceps  c,  Figure  210,  B.  Two  strong  ligatures 
en  masse  have  been  introduced  and  tied  one  on  each  side  of  the  pedicle.  These  ligatures 
control  the  ovarian  vessels.  The  black  and  white  dotted  line  shows  where  the  incision 
for  the  removal  of  the  pedicle  is  to  be  made. 

C  The  pedicle  has  been  removed  by  an  incision  along  the  dotted  line  shown  in 
B.  The  ligatures  which  surround  the  ovarian  vessels  en  masse  are  being  held  taut  each 
in  a  pressure  forceps,  while  a  tenaculum  makes  downward  traction  on  the  centre  of  the 
cut  edge  of  the  broad  ligament.  This  shows  the  cut  edge  folded  and  being  united 
upon  itself  by  a  continuous  suture. 

D.  The  suture  uniting  the  wound  in  the  broad  ligament  is  completed.  For  a  full 
description  of  the  technique  of  this  procedure,  see  Figures  125,  120,  127,  128,  and  129. 

29  477 


478  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

thick,  gelatinous  contents  of  colloid  cysts  and  the  contents  of  dermoid 
cysts  are  usually  infectious,  and,  if  brought  into  contact  with  the 
peritoneum,  may  cause  dangerous  infection.  In  order  to  avoid  such 
contamination  it  is  often  safer,  when  the  fluid  is  known  to  be  infec- 
tious, to  make  a  long  incision  and  deliver  the  tumor  intact  without 
attempting  to  puncture  the  cyst  and  draw  off  the  fluid. 

Emptying-  and  Delivery  of  the  Cyst. — As  soon  as  the  peritoneal 
cavity  is  opened,  the  cyst,  of  peculiar  blue  or  grayish-white  color,  is 
seen  directly  through  the  opening.  The  cyst  being  exposed,  the 
assistant  turns  the  patient  partly  on  the  side,  so  that  the  abdomen 
will  be  directed  toward  the  operator.  The  trocar,  with  an  attached 
rubber  tube,  then  is  thrust  through  the  cyst-wall,  and  the  fluid  is 
drawn  into  a  bucket  provided  for  the  purpose.     Figure  209. 

As  soon  as  the  fluid  begins  to  flow  the  cyst-wall  is  seized  close  to 
the  trocar  with  the  Nelaton  or  long  forceps — one  or  two  pairs — and  as 
the  sac  empties,  the  collapsing  walls  are  drawn  rapidly  through  the 
abdominal  wound.  A  non-adherent  monocyst  with  thin  walls  is 
delivered  in  this  way  with  great  ease. 

In  case  of  a  polycyst,  the  point  of  the  trocar  may,  without  com- 
plete withdrawal,  be  thrust  successively  into  one  compartment  after 
another  until  all  are  emptied  and  the  collapsed  sac  is  delivered. 

The  obstacles  to  the  delivery  of  the  sac  are  :  1.  Secondary  cysts. 
2.  Semisolid  contents,  and  solid  portions  of  the    cyst.     3.  Adhesions. 

1.  The  Secondary  Cysts  may  be  too  numerous  to  be  tapped  by  the 
trocar.  Delivery  may  then  be  accomplished  through  a  larger  incision,  or, 
the  trocar  having  been  withdrawn,  one  or  two  fingers,  and,  finally,  the 
left  hand,  introduced  into  the  sac  breaks  up  the  partitions  between  the 
secondary  cysts — as  it  were,  eviscerates  the  cyst.  During  this  manipu- 
lation the  forceps  in  the  right  hand  must  keep  the  opening  into  the  cyst- 
wall  drawn  well  outside  of  the  abdominal  incision  ;  this  is  important, 
in  order  to  prevent  escape  of  the  cyst-fluid  into  the  abdomen. 

2.  Semisolid  Contents  found  in  dermoid  and  colloid  cysts  wall  not 
run  through  the  trocar.  Often  tumors  are  partly  cystic  and  partly 
solid.  A  longer  incision  necessary  for  the  delivery  of  such  non-col- 
lapsible tumors,  is  made  upward  and  to  the  left  of  the  umbilicus, 
with  scissors,  the  left  index-finger  being  used  as  a  guide.     Figure  56. 

3.  Adhesions,  which  are  the  most  common  obstacle  to  the  easy  de- 
livery of  the  sac,  may  be  parietal  or  visceral.  The  general  technique 
in  adhesions  is  described  in  Chapters  VI.  and  XXIII.  The  cyst 
usually  should  be  tapped  and  the  fluid  drawn  off"  before  the  adhe- 
sions are  broken.  The  different  parts  of  the  sac  from  which  adhe- 
rent intestine,  omentum,  and  other  structures  are  to  be  separated  may 
usually  be  brought  successively  into  the  opening,  and  the  adhesions 
broken  until  the  tumor  is  free.  If  this  cannot  be  done,  the  inci- 
sion is  lengthened  and  the  adhesions  separated  in  situ.  In  loosen- 
ing the  adhesions  it  is  well  to  secure  bleeding  points,  as  they  occur, 
by  forcipressure,  or  torsion,  or  fine  catgut  ligatures.  The  tumor 
having  been  freed,  the  operation  proceeds  as  already  described  for 
non-adherent  tumors.  Figure  211,  A,  shows  adhesions  being  sepa- 
rated by  sponge  pressure. 

Lig'ature  of  the  Pedicle. — The  cyst  having  been  drawn  through 


OVARIOTOMY.  479 

the  abdominal  incision,  the  pedicle  is  treated  as  shown  in  Figures  128, 
129,  and  211. 

Closure  of  the  Wound,  Drainage,  and  After-treatment. — Tliese 
subjects  have  been  considered  fully  in  Chapters  VI.,  VII.,  and  A'lII. 

The  Accidents  and  Complications  are  such  as  may  occur  in 
abdominal  sections  performed  for  any  other  purpose. 

Extrusion  of  the  bowel  during  operation  should  be  prevented  by 
the  assistants  ;  if  it  occur,  the  bowel  should  be  returned  immediately 
and  held  inside  by  broad  gauze  pads  or  towels. 

Stripping  of  the  parietal  peritoneum  from  the  abdominal  wall,  under 
the  impression  that  it  is  an  adherent  cyst,  has  occurred  even  in  the 
hands  of  an  experienced  operator.  Peritoneum  thus  detached  is  apt 
to  slough  ;  and  therefore,  if  not  too  extensive,  should  be  removed  with 
the  tumor ;  if  it  is  not  removed,  there  should  be  drainage  of  the  space 
between  the  detached  peritoneum  and  the  subjacent  structures. 

Rupture  of  the  cyst- wall  and  escape  of  its  contents  are  harmless  if 
the  fluid  is  innocent;  unfortunately,  the  thin,  friable,  gangrenous 
cysts  that  are  apt  to  contain  infectious  fluids  are  the  ones  most  liable 
to  rupture.  The  clear  indication  after  rupture  is  thoroughly  to  irri- 
gate the  cavity  with  normal  salt  solution — 0.8  per  cent.  If  there  is 
anticipation  of  rupture,  one  may  pack  sponges  around  and  under  the 
cyst  to  absorb  the  fluid  as  it  escapes. 

Injuries  to  the  intestines,  ureter,  or  bladder  are  sometimes  unavoid- 
able. The  bowel  is  specially  liable  to  be  opened  in  breaking  up  adhe- 
sions. In  operating  deep  in  the  pelvis  the  bladder  or  ureter  may  be 
cut  even  by  a  careful  operator.  Injury  to  the  intestine  or  bladder 
should  be  repaired  immediately  by  suture.  If  the  ureter  has  been  cut, 
the  surgeon  will  have  recourse  to  one  of  the  following  procedures  : 
1.  The  cut  ends  may,  if  practicable,  be  reunited  by  end-to-end  approxi- 
mation after  the  method  of  Weller  Van  Hook.  2.  The  attempt  may 
be  made  to  turn  the  ureter  into  the  bladder.  3.  The  ureter  may  be 
brought  out  through  the  abdominal  wound.  4.  The  kidney  on  the 
affected  side  may  be  removed.     See  Chapter  XXIII. 

Foreign  bodies  left  in  the  abdomen,  such  as  sponges,  forceps,  and 
other  instruments,  have  caused  numerous  deaths,  not  only  after  ovari- 
otomy, but  after  other  abdominal  operations.     See  Chapter  VI. 

Intestinal  obstruction,  the  principles  of  drainage,  and  the  after-treat- 
ment have  been  presented  in  Chapters  VII.  and  VIII. 

Removal  of  Intraligamentous  Cysts. 

Ovarian  and  parovarian  cysts  which  develop  between  the  folds 
of  the  broad  ligament  and  are  called  intraligamentous,  have  been 
described  fully  in  Chapter  XXXII.  The  parovarian  cyst  is  easily 
peeled  out  of  the  broad  ligament.  The  papillomatous  ovarian  cysts 
may,  if  intraligamentous,  present  the  greatest  difficulties  in  removal, 
for  such  tumors  often  lie  deep  and  flrmly  fixed  in  the  substance  of  the 
broad  ligament,  and  are  therefore  difficult  to  enucleate. 

Before  attempting  the  enucleation  two  ligatures  or  temporary  lock 
forceps  should  be  applied,  one  on  the  infundibulopelvic  ligament, 
the  other  on  the  uterine  end  of  the  broad  ligament.    The  first  cuts  off" 


480  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS. 

the  ovarian  artery  as  it  enters  the  pelvis ;  the  second,  if  deeply  placed, 
cuts  off  the  utero-ovarian  anastomosis.  In  this  way  the  broad  liga- 
ment and  included  tumor  are  deprived  of  a  great  part  of  their  blood- 
supply,  and  the  troublesome  hemorrhage  sometimes  encountered  in  the 
removal  of  a  papillomatous  intraligamentous  cyst  therefore  may  be 
avoided  measurably.  In  order  to  control  hemorrhage  it  may  be  neces- 
sary to  ligature  also  the  uterine  vessels,  or  even  to  remove  the  uterus. 
The  tumor  may  be  removed,  according  to  its  depth,  in  one  of  two 
way :  If  it  is  not  very  deep,  and  lies  rather  loosely  in  the  broad  liga- 
ment, the  ligament  and  cyst  sometimes  may  be  excised  and  removed 
together.  This  procedure  is  very  much  like  that  described  in  Chapter 
XXIII.  for  the  removal  of  the  uterine  appendages.  The  other 
method  is  that  of  enucleation,  and  as  indicated  above  may  be  extremely 
difficult  and  hemorrhagic.  As  the  enucleation  proceeds  the  bleeding 
points,  so  far  as  possible,  are  secured  by  fine  catgut  ligatures.  The  sac 
having  been  removed,  the  raw  bleeding  surfaces  between  the  folds 
of  the  broad  ligament  are  packed  temporarily  with  hot  gauze  sponges 
to  check  the  oozing.  The  redundant  portions  of  the  ligament  may  be 
trimmed  off  with  the  scissors,  the  edges  may  be  turned  in  and  united 
with  deep  interrupted  or  continuous  sutures.  If  the  cavity  from 
which  the  sac  was  enucleated  is  too  large  to  be  obliterated  by  inver- 
sion and  suturing,  or  the  oozing  from  its  surface  is  uncontrollable,  an 
opening  may  be  made  from  the  bottom  of  the  cavity  close  to  the 
uterus  directly  into  the  vagina,  and  the  end  of  a  long  strip  of  gauze 
may  be  carried  through  this  opening  into  the  vagina,  the  cavity  packed 
full,  and  the  edges  of  the  broad  ligament  closed  over  the  packing. 
This  leaves  the  bleeding  part  entirely  covered  by  peritoneum,  renders 
the  raw  surfaces  extraperitoneal,  controls  hemorrhage,  and  provides 
for  drainage.  Care  to  avoid  the  ureters  is  necessary  in  the  enucleation, 
in  the  placing  of  deep  ligatures,  and  in  the  incision  into  the  vagina. 
The  gauze  drain,  which  is  the  same  as  that  described  in  Chapter 
XX  VII.,  may  be  removed  through  the  vagina  in  two  or  three  days. 

Ovariotomy  during  Pregnancy. 

An  ovarian  tumor  complicated  by  pregnancy  may  give  rise  to  the 
following  accidents:  1.  Twisting  of  the. pedicle.  2.  Abortion.  3. 
Obstruction  to  labor,  necessitating  Csesarean  section  or  ovariotomy 
during  labor.  From  these  and  other  possibilities  the  danger  of  labor 
to  child  and  mother  is  extreme.  Puncture  of  the  cyst,  as  a  temporary 
substitute  for  ovariotomy,  is  permissible  only  when  ovariotomy  is 
impracticable.  The  chief  danger  of  both  puncture  and  ovariotomy  is 
from  possible  sepsis  and  consequent  abortion  or  premature  labor.  In 
the  complication  of  pregnancy  the  necessity  for  an  early,  rapid, 
gentle,  aseptic  ovariotomy  is  apparent.  The  pedicle  always  contains 
large    vessels,    and   should  therefore  be  tied  with  special  care. 

Vaginal  Ovariotomy. 

The  vaginal  route  offers  no  advantage  even  in  cases  of  small 
pedunculated  non-adherent  cysts,  and  should  seldom,  if  ever,  be  pre- 
ferred to  the  abdominal  route. 


CHAPTER    XXXV. 

TUMORS  OF  THE  FALLOPIAN  TUBES,  BROAD  LIGAMENTS, 
ROUND  LIGAMENTS,  AND  URINARY  ORGANS. 

TUMORS  OF  THE  FALLOPIAN  TUBES. 

The  tumors  of  tlie  Fallopian  tubes  iuclude  myoma,  adenoma, 
adenomyoma,  cysts,  carcinoma,  and  sarcoma. 

Myoma  of  the  tube  rarely  occurs,  seldom  obstructs  the  oviduct, 
and  is  commonly  too  small  to  be  of  clinical  significance.  One  case, 
however,  is  reported  in  which  the  tumor  reached  the  size  of  a  child's 
head.^  Salpingitis  isthmica  nodosa  and  tubercular  salpingitis  have 
been  mistaken  for  myoma  of  the  tube. 

Adenoma,  as  termed  by  J.  Bland  Sutton,^  or  papilloma,  as  first 
described  by  Doran,^  is  found  not  uncommonly.  The  growth  usually 
begins  as  a  small  papilloma  or  wart,  and  may  attain  the  size  of  a  large  _ 
orange.  It  may  present  the  appearance  of  a  so-called  hydatid  mole, 
a  multiple  cyst,  or  a  cauliflower  growth.  A  frequent  comj)lication, 
according  to  Sutton,  is  hydroperitoneum.  This  results  when  the 
abdominal  end  of  the  tube  is  open  and  the  secretion  passes  from  the 
tube  into  the  peritoneum.  When  the  abdominal  end  is  closed  and  the 
uterine  end  open,  there  may  be  a  discharge  through  the  uterus.  Adeno- 
mata frequently  undergo  malignant  degeneration  ;  early  removal  of 
the  tube  therefore  is  indicated. 

Adenomyoma  is  characterized  by  small  nodular  enlargements  of 
the  Fallopian  tube.  It  has  been  described  fully  by  Recklinghausen, 
and  later  by  Ries,  as  originating  in  the  remnants  of  the  Wolffian 
body.  The  various  nodular  enlargements  of  the  tube,  including 
salpingitis  isthmica  nodosa  and  adenomyoma,  may  be  caused  by  a 
number  of  pathological  conditions.  The  diiferential  diagnosis  between 
them  must  be  made  by  the  microscope.  They  cannot  be  distinguished 
by  clinical  examination. 

Cysts  of  the  tube  are  of  frequent  occurrence,  but  of  little  clinical 
importance.  Small  pedunculated  cysts,  known  as  hydatids  of  Mor- 
gagni,  are  often  to  be  found  at  the  fimbriated  extremity.  Numerous 
minute  cysts  with  thin  walls  are  seen  frequently  on  the  mucous  sur- 
face of  the  tubes. 

Carcinoma,  as  a  primary  growth,  is  very  rare  in  the  tube,  and, 
when  present,  is  usually  the  outgrowth  of  adenoma.  Secondary  car- 
cinoma may  be  the  result  of  extension  from  the  ovary  or  the  body  of 

1  Sir  J.  Y.  Simpson.    From  System  of  Gynecology.  Plavfair  and  AUbutt. 
^  Surgical  Diseases  of  the  Tubes  and  Ovaries.    J.  Bland  Sutton. 

3  Transactions  of  the  Pathological  Society  of  London,  vol.  xxxi.,  p.  174.    Surgical  Diseases 
of  the  Tubes  and  Ovaries.    J.  Bland  Sutton. 

481 


482  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

the  uterus.     It  is  seldom,  if  ever,  secondary  to  cancer  of  the  cervix 
without  first  involving  the  body  of  the  uterus. 
Sarcoma  of  the  tube  is  exceedingly  rare. 

TUMORS    OF    THE   BROAD    LIGAMENT. 

Tumors  of  the  broad  ligament  include  myoma,  lipoma,  cystoma, 
carcinoma,  and  sarcoma. 

Myoma  and  Lipoma  are  pathological  curiosities  and  do  not  grow 
to  large  size.     The  other  growths  have  been  described. 

TUMORS    OF   THE   ROUND    LIGAMENT. 

Tumors  of  the  round  ligament  include  myoma,  fibroma,  cyst  or 
hydrocele,  sarcoma,  and  carcinoma. 

Myoma  and  Fibroma  are  rare,  but,  according  to  Coe,  are  more 
common  in  multipara  than  in  nullipara,  and  more  frequent  on  the  right 
than  on  the  left  side.  The  growth  may  be  intraperitoneal  or 
extraperitoneal.  Myoma  is  commonly  pedunculated,  hard,  of  slow 
growth,  painless,  not  tender  to  pressure,  and  may  be  either  smooth  or 
lobulated.  When  large,  it  may  cause  pressure-symptoms ;  if  extra- 
peritoneal, it  may  be  found  in  the  inguinal  canal  or  in  the  labium 
majus.     During  pregnancy  it  may  increase  rapidly  in  size. 

The  Diagnosis  is  from  ovarian  and  omental  hernia,  enlarged  in- 
guinal glands,  and  cysts  of  the  glands  of  Bartholin.  Ovarian  heimia 
is  differentiated  from  myoma  of  the  round  ligament  by  its  ovoid  form, 
tenderness  on  pressure,  possibility  of  reduction  on  pressure,  and  by 
its  increase  in  size  during  menstruation.  Omental  hernia  may  be  as 
hard  as  myoma  and  impossible  to  recognize  without  an  exploratory 
incision.  Enlarged  inguinal  glands  are  distinguished  by  the  history 
of  infection,  by  the  lobulated  outline,  and  by  the  presence  usually  of 
more  than  one  enlarged  gland.  Oysts  of  the  glands  of  Bartholin  are 
distinguished  by  their  location.  In  myoma  the  tumor  originally  lies 
above  the  location  of  the  glands  of  Bartholin.  Exploratory  puncture 
will  serve  to  identify  the  cyst. 

The  Treatment  is  extirpation. 

Cyst  or  Hydrocele  is  supposed  to  be  developed  within  the  canal 
of  the  embryonic  round  ligament,  the  embryonic  ligament  being 
hollow  instead  of  solid.  It  may  appear  in  the  form  of  several  cysts, 
or  of  a  collection  of  fluid  either  within  the  inguinal  canal  or  at  the 
external  ring.  Schroeder  reports  a  case  in  which  there  seemed  to  be 
a  communication  between  the  cyst  and  the  peritoneal  cavity ;  at 
least  the  fluid  could  be  forced  by  pressure  inside  the  abdomen.  The 
writer  never  has  observed  a  case  of  hydrocele  in  the  round  ligament. 

The  Differential  Diagnosis  is  from  myoma  of  the  ligament  and  in- 
guinal hernia.  From  myoma  it  is  distinguished  by  the  sense  of  fluc- 
tuation and  by  exploratory  puncture.  From  hernia  the  growth  is 
distinguished  by  not  transmitting  an  impulse  on  coughing,  by  failure 
to  reduce  by  taxis,  and  by  fluctuation. 

The  Treatment  is  extirpation  of  the  sac  and  direct  suturing. 


TUMORS  OF  THE   URETHRA. 


483 


Sarcoma  and  Carcinoma  are  so  rare  as  to  be  of  interest  chiefly 
as  pathological  curiosities. 


TUMORS    OF    THE   URETHRA. 

The  principal  varieties  of  urethral  tumor  are  caruncle,  mucous 
polypus,  condyloma,  wart,  carcinoma,  and  sarcoma.  The  most  fre- 
quent seat  is  the  meatus  urinarius.  Carcinoma  and  sarcoma  are  apt 
to  occur  by  extension  from  the  vulva  or  vagina.     Chapter  XXV. 

Figure  212. 


Polypus  in  the  bladder. 

Urethral  Caruncle  is  a  growth  which  occurs  quite  frequently  in 
nervous,  irritable  women,  and,  although  no  age  is  exempt,  it  is  most 
frequent  near  the  menopause. 

Pathology.^ — Urethral  caruncles  are  usually  of  the  granuloma, 
papilloma,  or  telangiectatic  (dilated  blood-vessels)  type. 

Etiology. — Irritating  discharges  from  above,  especially  the  dis- 
charges of  gonorrhcea,  senile  endometritis,  and  vulvovaginitis,  are 
the  commonly  assigned  causes. 

1  M.  Jjange.    Zeitschrift  fiir  Geburtshulfe  und  Gy^nakologie. 


484 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


Diagnosis. — This  growth  is  of  frequent  occurrence,  and  is  a  small, 
soft,  red,  friable,  hemorrhagic  mass  situated  usually  at  the  margin 
and  on  the  vaginal  side  of  the  meatus  urinarius.  It  may,  however,  be 
anywhere  in  the  urethra.  There  is  usually  a  previous  history  of 
pelvic  disease.  There  often  is  associated  great  sensitiveness  or  ex- 
treme pain  on  urination  ;  but,  according  to  Lange,  this  pain  is  due  not 
so  much  to  the  growth  itself  as  to  the  complications. 

The  Differential  Diagnosis  from  Skene's  glands  has  been  given 
in  Chapter  XXIV.  The  growths  may  be  differentiated  from  other 
tumors  in  the  same  region  by  the  constant  finding  of  urethral  glands 
in  the  caruncle,  although  the  structure  of  the  glands  is  modified  fre- 
quently by  hemorrhage,  round-cell  infiltration,  and  prolapse  of  the 

Figure  213. 


Carcinoma  in  the  bladder. 


urethra  so  that  the  free  surface  of  the  caruncle  no  longer  bears 
cylindrical  nor  transitional  epithelium. 

Treatment. — The  treatment  is  excision  with  the  scissors  under  the 
base  of  the  growth,  and  when  practical  union  of  the  wound  by  suture. 
Excision  may  require  dilatation  of  the  urethra,  as  described  in  Chap- 
ter III.,  or  Urethrotomy,  as  described  in  Chapter  XXIV.  The 
actual  cautery,  though  commonly  used,  is  objectionable  on  account  of 
unreliability  and  because  of  its  destructive  and  cicatricial  effects.  The 
frequency  with  which  these  growths  return  after  surgical  removal  is 
due  undoubtedly  to  the  failure  of  operators  to  treat  successfully  the 
causative  complications. 

Warts,  Mucous  Polypi,  Carcinoma,  and  Sarcoma  follow  the 
same  principles  of  pathology,  diagnosis,  prognosis,  and  treatment  as 
when  they  occur  in  the  vulva. 


TUMORS  OF  THE  BLADDER.  485 

TUMORS    OF    THE    BLADDER. 

Tumors  originating  in  the  bladder  are  rare.  They  occur  much  less 
frequently  in  the  female  than  in  the  male  bladder. 

Benign  tumors,  especially  if  polypoid,  are  removed  easily  through 
an  artificial  vesicovaginal  fistula.  Hsemostasis  may,  if  necessary,  be 
secured  by  leaving  the  forceps  for  a  time  on  the  stump.  A  sessile 
growth,  on  account  of  its  inaccessibility  and  its  hemorrhagic  tenden- 
cies, is  much  more  difficult  of  removal.  Diagnosis  is  made  by  cystos- 
copy. 

Malignant  disease  is  in  a  majority  of  cases  an  extension  from  the 
cervix  uteri,  and  in  such  cases  the  treatment  is  wholly  palliative. 
Small  carcinomata  originating  in  the  bladder  may  be  removed  with 
some  hope  of  cure. 

The  differential  diagnosis  of  vesical  tumors  is  from  calculi  and 
other  foreign  bodies  in  the  bladder.  Figures  212  and  213  show 
polypus  and  carcinoma  in  the  bladder. 


CHAPTER    XXXV  L 

TUBAL  PREGNANCY. 

Tubal  pregnancy  includes  all  forms  of  gestation  that  originate 
outside  the  uterine  cavity.  The  old  idea,  that  extra-uterine  preg- 
nancy comprised  three  types — viz.,  tubal,  ovarian,  and  abdominal— is 
obsolete ;  no  authentic  case  of  gestation  originating  upon  the  perito- 
neum has  ever  come  to  light.  Some  claims  have  been  made  of  preg- 
nancy originating  in  the  ovary,  but  the  evidence  in  support  of  these 
claims  hardly  amounts  to  proof.  So  far  as  known,  all  ectopic  gesta= 
tions  with  the  possible  exception  of  a  very  few  ovarian  pregnancies 
originate  in  the  Fallopian  tube.  Pregnancy  in  a  rudimentary  horn  of 
a  bicornate  uterus  is  virtually  a  tubal  pregnancy. 

Ectopic  pregnancy  formerly  was  considered  a  rare  condition. 
Now  we  know  it  to  be  of  relatively  common  occurrence.  Pelvic 
hsematocele,  formerly  attributed  to  other  causes,  is  recognized  now,  in 
the  vast  majority  of  cases  at  least,  as  being  due  to  rupture  of  the 
gestation-sac  of  tubal  pregnancy. 

Etiology  of  Tubal  Pregnancy. 

It  is  conceded  generally  that  in  at  least  a  large  proportion  of  cases 
normal  fertilization  of  the  ovum  occurs  in  the  Fallopian  tubes.  Sper- 
matozoa have  been  found  in  the  fimbriated  extremity  of  the  tube, 
and  it  is  probably  here  that  they  unite  norrnally  with  the  ovum.  The 
diameter  of  the  human  unimpregnated  ovum  is  not  over  two-tenths 
of  a  millimetre  ;  that  of  the  tube,  two  or  three  millimetres ;  although 
after  impregnation  the  ovule  rapidly  increases  in  size,  yet  under  ordi- 
nary conditions  there  is  ample  time  for  it  to  pass  into  the  uterus  before 
disproportionate  enlargement  takes  place.  The  question  of  the  size 
of  the  tube,  therefore,  is  not  very  pertinent  to  this  discussion. 

Tubal  pregnancy  is  common  after  long  periods  of  sterility.  This 
is  explained  possibly  by  the  fact  that  the  sterility  may  have  been  due 
to  chronic  salpingitis,  which,  by  thickening  of  the  tube  and  destruc- 
tion of  the  cilia,  prevented  the  normal  passage  of  the  ovule  to  the 
uterus  and  at  the  same  time  favored  the  implanation  of  it  in  the 
tube. 

According  to  Webster,^  tubal  pregnancy  is  explained  as  follows  : 
In  the  earlier  type  of  mammalian  development  the  uterus  was  bicor- 
nate— that  is,  composed  of  two  horns,  of  which  the  Fallopian  tubes  in 
the  woman  are  mere  rudiments.  In  other  words,  the  uterus  consisted 
of  two  highly  developed  Fallopian  tubes.  In  some  women  even  now 
he  believes  there  is  a  structural  or  functional  reversion  to  the  ancient 

1  Ectopic  Pregnancy. 


TUBAL  PREGNANCY.  487 

type.  According  to  this  theory,  the  stronger  the  tendency  to  rever- 
sion the  greater  the  liability  to  tubal  pregnancy.  This  might  explain 
the  fact  of  repeated  tubal  pregnancies  observed  in  the  same  indi- 
vidual. 

Peritonitic  adhesions  and  bands  obstructing  the  tubes  are  frequent 
in  ectopic  pregnancy ;  but  whether  they  cause  the  morbid  condition 
or  result  from  it,  or  are  only  incidental,  is  uncertain. 

There  is  considerable  authentic  literature  on  the  transmigration  of 
the  ovum  from  the  ovary  of  one  side  to  the  tube  of  the  other.  Both 
clinical  and  experimental  exam])les  have  been  well  attested  in  which 
pregnancy  occurred  in  the  tube  when  the  ovary  on  that  side  was 
absent.  There  has  been  atresia  of  one  tube  and  tuljal  pregnancy  in 
the  other,  but  with  the  corresponding  corpus  luteum  only  in  the 
ovary  of  the  closed  side.  All  this  proves  that  the  ovimi  must  have 
passed  across  the  j^elvic  cavity  to  the  tube  in  which  it  finally  lodged. 
Tubal  pregnancy,  therefore,  may  occur  under  most  unfavorable 
conditions. 

The  following  is  a  summary  of  the  supposed  predisposing  causes, 
none  of  which  accounts  entirely  for  the  phenomena  : 

1.  Inflammation  of  the  Fallopian  tubes  causing  : 

a.  Desquamation  of  ciliated  epithelium  and  denuded  patches 

which  obstruct  the  ovum. 
h.  Loss  of  peristaltic  action  of  the  tube. 
c.   Cicatricial  contraction  in  the  tube. 

2.  Persistence  of  foetal  type — tube  long  and  tortuous,  with  small 
lumen. 

3.  New  formations  in  and  around  the  tube. 

4.  Torsion  of  the  tube. 

5.  Diverticula  in  the  tube. 

6.  Conditions  giving  rise  to  sterility  of  long  standing. 

Formation  of  Chorion,  Amnion,  Decidua,  and  Placenta.^ 

During  the  first  month  or  six  weeks  of  tubal  pregnancy  that 
portion  of  the  tube  in  which  the  fertilized  ovum  is  lodged  becomes 
thinner  and  very  vascular  and  turgid.  The  mucous  membrane  be- 
comes stretched  and  its  folds  effaced.  The  changes  that  occur  in  the 
fertilized  ovum  after  impregnation  are  identical,  whether  it  be  in  the 
tube  or  the  uterine  cavity.  The  membranes  by  which  the  embryo  is 
enclosed  are  similar  to  those  in  intra-uterine  gestation.  These  mem- 
branes can  be  studied  to  advantage  in  the  so-called  tubal  moles,  which 
are  similar  in  origin  to  uterine  moles.  The  chorion  is  shaggy  with 
villi,  and  resembles  in  gross  and  microscopical  appearances  that  found 
in  intra-uterine  gestation.  The  villi  appear  as  clusters  of  circular 
bodies.  The  embryo  lies  within  the  amniotic  cavity,  and  the  struct- 
ure of  the  amnion  and  its  relations  to  the  embryo  and  chorion  are 
almost  the  same  as  in  intra-uterine  pregnancy. 

The  formation  of  the  placenta  in  tubal  gestation  differs  in  several 
particulars  from  one  developed  in  the  uterus.     In  normal  gestation 

1  J.  Bland  Suttou,  in  Allbutt  and  Plaj-fair's  System  of  Gynecology. 


488  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS. 

the  uterine  mucosa  and  the  foetal  structures  both  contribute  to  the 
formation  of  the  placenta ;  but  in  tubal  pregnancy  the  tubal  mucosa 
plays  a  very  insignificant  part.  A  tubal  placenta  is  derived  almost 
entirely  from  the  embryo. 

Contrary  to  Sutton,  Webster  has  demonstrated  a  decidua  in  the 
tube.  It  is  a  curious  fact  that  in  addition  to  this  tubal  decidua  a 
decidua  also  forms  in  the  uterus ;  it  is  thrown  oif  during  false  labor, 
or,  if  the  patient  goes  to  term,  is  expelled  later  in  small  fragments 
and  without  pain.  This  intra-uterine  decidua  has  all  the  elements  of 
a  decidua  of  normal  intra-uterine  pregnancy. 

The  muscular  layers  of  the  tube  (myosalpinx)  at  first  undergo 
hypertrophy,  but  soon  that  portion  to  which  the  placenta  is  attached 
becomes  thinned,  and  the  bundles  of  muscular  fibres  are  separated ; 
this  favors  early  rupture. 

Frequency  of  Tubal  Pregnancy. 

Tubal  pregnancy  is  not  infrequent.  Indeed,  pelvic  hsematocele, 
which  is  not  uncommon,  is  almost  invariably  the  result  of  ectopic 
gestation.  In  thirty-five  hundred  general  autopsies  Formad  found 
thirty-five  ectopic  pregnancies,  or  1  per  cent.  This  is,  perhaps,  the 
largest  percentage  reported.  The  extirpation  of  diseased  tubes  has 
brought  to  light  many  cases  of  tubal  gestation  that  otherwise  would 
not  have  been  recognized,  and  thereby  has  added  to  our  estimate  of 
their  frequency  ;  this  estimate  is  increased  still  further  by  microscopical 
diagnosis  of  the  decidua  cast  off  by  the  uterus  in  the  spurious  labor 
which  always  occurs  at  some  period  of  tubal  pregnancy. 

Repetition  of  tubal  pregnancies  in  the  same  individual  has  been 
noticed  above.  Both  tubes  may  be  simultaneously  pregnant.  Twin 
tubal  pregnancy  in  the  same  tube  and  concurrent  tubal  and  uterine 
gestation  have  been  reported.  There  is  no  absolute  rule  as  to  the  fre- 
quency of  the  condition  on  either  side.  Tubal  pregnancy  has  been 
reported  after  extirpation  of  the  uterus,  the  tube  still  having  a  con- 
nection with  the  vagina.^ 

Varieties  of  Tubal  Pregnancy. 

Tubal  pregnancies  occur  at  the  uterine  end,  the  middle  region, 
or  near  the  abdominal  extremity  of  the  tube,  and  are  designated 
respectively  : 

1.  Interstitial  pregnancy. 

2.  Isthmic  pregnancy. 

3.  Ampullar  pregnancy. 

The  subvarieties  will  be  noticed  in  describing  each  type.  The 
primary  classification  depends  upon  the  original  site  of  implantation, 
not  upon  subsequent  accidents  of  development  or  secondary  changes. 
A  normal  pregnancy  may  become  extra-uterine  by  rupture  of  the 
uterus,  as  in  a  case  reported  by  Leopold,^  but  that  does  not  make  it 
extra-uterine  in  the  sense  here  considered. 

'  Wendiles.  Monatschrift  fiir  Geburtshalfe  und  Gvnakologie,  1895.  Centralblatt  fiir  Gyna- 
kologie,  No.  4,  1896.  '  2  Archiv  fiir  Gynakologie,  Ivii.,  1896. 


TUBAL  PREGNANCY. 


489 


1.  Interstitial  Tubal  Pregnancy. — This  is  by  far  the  least  fre- 
quent form.  Lodgement  of  the  ovum  takes  place  in  that  part  of  the 
tube  which  traverses  the  uterine  wall,  and  the  foetus  develops  in  a 
cavity  formed  in  the  substance  of  the  uterus.     This  'cavity  may  open 

Figure  214. 


In  the  right  lube  isthmic  pregnancy,  about  third  month.  Embryo  with  unbroken  mem- 
branes protruding  through  the  ruptured  tube. 

In  the  left  tube  interstitial  pregnancy.  The  embryo  lies  in  the  uterine  wall  between  the 
left  horn  of  the  uterus  and  the  isthmus  of  the  tube. 

into  that  of  the  uterus,  making  a  tubo-uterine  pregnancy  ;  or  in  rare 
instances  it  may  extend  outward  between  the  layers  of  the  broad  liga- 
ments.    Webster^  concludes  that  in  some  cases  of  interstitial  preg- 

FlGXJRE  215. 


Ampullar  pretrnancy.  Fimbriated  extremity  of  the  tube  closed  by  adhesions,  which  renders 
tubal  abortion  impossible  and  rupture  inevitable.  Observe  a  decidua  of  pregnancy  which  has 
developed  in  the  endometrium. 

nancy  the  ovum  develops  in  the  side  wall  of  the  uterus,  in  a  diver- 
ticulum formed  by  the  incomplete  fusion  of  Mueller's  ducts  which 
sometimes  occurs  in    this  particular  region.     Pregnancy  in    a    rudi- 

'  Ectopic  Pregnancy. 


490  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS. 

mentary  horn  of  the  uterus,  although  having  a  pathology  of  its  own, 
is  yet  not  unlike  tubal  pregnancy.  The  course  and  outcome  of  in- 
terstitial pregnancy  will  be  noticed  later  in  connection  Nvith  that  of 
the  other  forms. 

2.  Isthmic  Pregnancy  is  more  frequent  than  interstitial,  less  fre- 
quent than  ampullar,  pregnancy.  The  ovum  is  lodged  in  the  middle 
region  ;  and  there  is  generally,  before  rupture,  a  spindle-shaped  dilata- 
tion of  the  tube.  So-called  pedunculated  tubal  pregnancy  is  possible 
in  this  part  of  the  tube,  and  in  a  few  cases  has  gone  to  term.  This 
occurs  when  the  ovum  is  lodged  in  a  diverticulum  or  angle  of  the 
tube.  Under  such  conditions  the  walls  of  the  tube  may  be  thick  or 
thin  in  parts,  with  consequent  greater  liability  to  rupture  in  the  thin 
parts. 

3.  Ampullar  Pregnancy. — This  is  the  common  variety.  The 
attachment  of  the  ovum  takes  place  in  the  ampulla  or  outer  third  of 
the  tube.  Tubo-ovarian  pregnancy  is  a  subdivision  of  ampullar  preg- 
nancy and  occurs  when  there  is  prior  adhesion  of  the  ampulla  to  the 
ovary,  so  that  both  contribute  to  form  the  gestation-sac. 

Development  and  Course  of  Tubal  Gestation. 

After  the  ovum  has  attached  itself  to  the  tubal  wall  it  continues  to 
develop.  Naturally  the  conditions  are  not  so  favorable  as  in  normal 
gestation  ;  the  tubal  walls  are  suited  less,  and  contribute  less  fully  to 
the  nourishment  and  development  of  the  embryo  than  does  the 
uterus  in  normal  pregnancy.  Unless  the  ovum  is  inserted  well  in 
toward  the  uterus,  as  in  interstitial  pregnancy,  the  whole  tube  becomes 
extra  vascular,  turgid,  thinner,  and,  in  most  cases,  less  and  less  resistant. 
The  margin  of  peritoneum  around  the  ostium  abdominale  thickens 
and  forms  a  ring  about  the  fimbriae.  This  ring  by  the  eighth  week 
usually  closes  over  and  shuts  the  tube.  The  development  of  the 
embryo  in  the  tube,  so  far  as  the  conditions  will  permit,  follows  the 
same  course  as  in  the  uterus. 

As  the  foetus  enlarges,  the  course  of  gestation  will  be  modified  in 
one  of  the  following  ways  : 

a.  The  foetus,  if  in  or  near  the  ampulla,  may  be  expelled  from  the 
tube  through  the  ostium  abdominale  into  the  abdominal  cavity.  This 
is  called  tubal  abortion. 

6.  The  tube  may  rupture  and  partly  or  wholly  discharge  the  foetus 
in  one  of  four  directions  : 

1.  Into  the  abdominal  cavity. 

2.  Into  the  space  between  the  broad  ligaments. 

3.  Into  a  space  formed   by   adhesions   between   the  tube   and 

ovary. 

4.  Into  the  uterus. 

c.  The  foetus  may  remain  in  the  tube  and  die  before  maturity  or 
go  on  to  term. 

a.  Tubal  Abortion  necessarily  occurs  Avhile  the  ostium  abdom- 
inale is  still  open — that  is,  before  the  eighth  week.  The  nearer  the 
implantation  of  the  ovule  to  the  ostium,  the  greater  the  liability  to 


TUBAL  PREGNANCY.  491 

abortion.  In  this  accident  the  product  of  conception — sometimes 
called  tubal  mole — is  discharged  with  free  hemorrhage  through  the 
still  open  ostium  into  the  abdominal  cavity.  The  hemorrhage  gives 
rise  \p  the  formation  of  intraperitoneal  pelvic  hsematocele.  The  acci- 
dent may  be  fatal  from  shock  and  loss  of  blood,  or  the  patient  may 
recover.  In  some  cases  the  mole  lies  quiescent  in  the  tube  ;  and  if  only 
partially  detached,  it  gives  rise  to  repeated  and  dangerous  hemorrhage. 
The  false  uterine  decidua  usually  is  thrown  off  with  uterine  hemor- 
rhage when  the  tubal  abortion  takes  place.  The  latter  occurrence 
may  be  masked,  as  it  were,  by  the  uterine  hemorrhage.  Tubal 
abortion  does  not  occur  in  interstitial  and  is  rare  in  isthmic  pregnancy  ; 
after  occlusion  of  the  ostium  it  can  hardly  occur  even  in  the  ampullar 
variety. 

b.  Tubal  Rupture. — Rupture  of  the  tube  may  occur  at  any  period. 
It  is  not  very  usual  in  the  first  month,  is  quite  liable  to  occur  in  the 
second,  and  rapidly  becomes  less  frequent  after  the  beginning  of  the 
third,  still  less  in  the  fourth.  It  may  be  due  to  direct  tension  on  the 
tubal  walls  from  the  growing  foetus,  but  is  brought  about  commonly 
by  hemorrhage  between  the  ovum  and  the  sac.  Among  the  other 
causes  are  mechanical  violence  from  falling,  jumping,  digital  examina- 
tion, and  coitus.  The  rupture  usually  takes  place  where  the  hemor- 
rhage begins — that  is,  at  the  placental  insertion.  The  foetal  mem- 
branes are  not  necessarily  involved  in  the  tear.  If  the  ovum  still 
retains  its  placental  insertion,  as  it  does  in  rare  cases,  it  may  continue 
to  grow.  More  commonly  it  is  extruded  through  the  ruptured  tubal 
wall  and  passes  into  the  abdominal  cavity  ;  or  it  may  pass  dowaiward 
between  the  folds  of  the  broad  ligament  or  into  a  cavity  formed  by 
adhesions  between  the  tubal  wall  and  the  ovary. 

Rupture  in  interstitial  pregnancy  may  be  either  into  the  abdomen, 
where  it  is  apt  to  be  rapidly  fatal  from  hemorrhage  and  shock,  or  into 
the  uterine  cavity,  where  the  pregnancy  may  continue  as  in  normal 
gestation.  Rupture  into  the  uterus  may  occur  much  later  than  the 
fourth  month. 

If  the  foetus  in  ampullar  or  isthmic  pregnancy  is  not  entirely  cut 
oif  by  rupture  or  abortion  from  its  nutritive  connections,  or  disorgan- 
ized by  hemorrhage,  and  especially  if  the  rupture  is  into  the  space 
between  the  folds  of  the  broad  ligaments  or  into  a  tubo-ovarian  cavity, 
gestation  may  go  to  full  term.  If  the  foetus  and  its  investing  mem- 
branes escape  into  the  general  peritoneal  cavity,  the  placenta  remain- 
ing in  the  tube,  it  is  possible,  though  rare,  for  development  to  continue. 

The  notion  that  a  free  embryo  can  escape  and  ingraft  itself 
on  the  peritoneum  is  obsolete.  The  experiments  of  Leopold  on  dogs 
demonstrate  the  great  absorbing  power  of  the  peritoneum,  and  indi- 
cate that  no  organism  thus  introduced  could  survive. 

If  rupture  occurs  very  early  in  pregnancy,  hemorrhage  may  be 
less  severe  ;  but  after  the  first  month  it  is  apt  to  be  formidable  and 
may  cause  death  in  a  few  hours.  If  the  hemorrhage  is  slight,  we 
have  the  common  type  of  retro-uterine  haematocele,  which,  if  not 
aggravated  by  repeated  bleedings,  is  generally  encysted  and  gradually 
absorbed.     In  isthmic  and  ampullar  gestation  the  rupture  is  often 


492 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


downward  between  the  layers  of  the  broad  ligament.  The  blood  is 
then  poured  out  into  this  confined  space.  The  natural  tendency  of 
this  confinement  is  to  check  the  hemorrhage.  The  blood  thus  accum- 
ulated is  called  a  broad-ligament  heematocele.  The  more  gradual  the 
rupture  and  the  more  slight  the  hemorrhage,  the  less  wall  be  the  gen- 
eral and  local  disturbance.  Under  such  conditions  the  embryo  and  its 
envelopes  and  placenta  will  have  a  better  chance  to  adapt  themselves 
to  their  enlarged  and  enlarging  quarters,  and  may  go  on  to  term. 


Figure  216. 


Secondary  abdominal  pregnancy  after  term  ;  primarily  tubal.  The  original  attachment 
of  the  placenta  may  be  seen  in  the  ruptured  tube.  Alter  ruplure  the  embryo  developed  out- 
ward, and  became  adherent  to  the  peritoneum.  Operation  at  St.  Luke's  Hospital  by  lapa- 
rotomy. Macerated  child  removed.  The  contents  of  the  gestation-sac  were  purulent  and 
extremely  fetid.  The  incision  was  made  directly  through  the  abdominal  wall  into  the  sac 
without  invading  the  general  abdominal  cavity.    Recovery. 

If  the  escaped  embryo  develops  in  a  cavity  formed  by  the  two 
layers  of  the  broad  ligament  and  the  outer  wall  of  the  tube,  the  preg- 
nancy is  called  tiihoUgamentous.  As  the  foetus  develops  it  presses 
aside  and  displaces  other  organs,  the  layers  of  the  broad  ligament 
become  compressed  or  thickened  and  form  adhesions  to  surrounding 
parts,  the  peritoneum  is  pressed  upward  and  stripped  from  the 
bladder  and  abdominal  wall,  the  uterus  is  displaced  to  the  opposite 


TUBAL  PREGNANCY.  493 

side  and,  according  to  the  direction   of  pressure,   upward  or  down- 
ward. 

If  the  placenta  is  situated  in  the  upper  part  of  the  tube,  so  that  it 
is  pressed  up  above  the  foetus  toward  the  abdomen,  forming  a  tubal 
placenta  prsevia,  the  danger  from  secondary  rupture  of  the  gestation- 
sac  into  the  abdomen  is  very  great ;  such  an  accident  is  apt  to  be 
fatal.  If  the  placenta  is  situated  below  the  foetus  toward  the  meso- 
salpinx, and  pressed  down  upon  the  pelvic  floor,  this  danger  is  less 
imminent ;  for  rupture  in  this  situation,  since  it  does  not  of  necessity 
directly  involve  the  placenta,  is  attended  with  less  hemorrhage  and 
less  risk. 

All  isthmic  and  ampullar  pregnancies,  if  left  to  nature,  end  with 
death  of  the  foetus.  The  tubo-uterine  variety  of  interstitial  preg- 
nancy may,  as  already  explained,  result  in  the  passage  of  the  embryo 
into  the  uterine  cavity  and  subsequent  normal  gestation. 

.c.  In  rare  instances  the  pedunculated  isthmic  pregnancy  already 
mentioned  may  go  to  terra  in  the  unruptured  tube. 

Secondary  Changes  in  Connection  with  Tubal  Gestation. 

If  the  death  of  the  foetus  occur  in  the  earlier  weeks  and  the 
mother  survive,  the  subsequent  conditions  will  vary  according  as  the 
embryo  is  retained  in  its  envelopes  or  is  cast  out  free  into  the  abdominal 
cavity.  In  the  latter  case  it  may  be  absorbed  quickly ;  in  the 
former,  absorption,  although  slower,  is  the  usual  ultimate  result.  Ges- 
tation that  has  advanced  for  several  months  may  give  rise  to  a  variety 
of  changes.  The  foetus  may  undergo  a  process  of  mummification  and 
remain  encapsulated  in  the  body  of  the  mother  for  years.  Chiari  has 
reported  a  case  in  which  the  mummified  foetus  was  carried  for  fifty 
years.  It  may  undergo  calcareous  degeneration,  so-called,  and  become 
a  lithopsedion,  and  remain  in  that  state  for  years.  The  mummified  or 
calcareous  foetus  ordinarily  gives  little  trouble  ;  it,  however,  may  be- 
come the  seat  of  suppuration,  and  as  a  consequence  the  patient  may 
succumb  to  exhaustion  from  peritonitis  or  blood-poisoning.  On  the 
other  hand,  spontaneous  opening  of  the  abscess  into  the  intestine  or 
vagina,  or  through  the  abdominal  walls,  may  lead  to  recovery.  A 
lithopsedion  has  been  the  mechanical  cause  of  obstruction  in  labor. 
The  formation  of  a  uterine  decidua  and  its  discharge  in  tubal 
pregnancy  have  been  mentioned.  The  musculature  of  the  uterus 
undergoes  hypertrophy  ;  the  organ  may  enlarge  to  the  size  of  the 
second  or  third  month  of  pregnancy,  and  then  to  some  extent  dimin- 
ish. If  the  tubal  pregnancy  is  interrupted  by  abortion  or  rupture, 
the  uterus  generally  at  the  same  time  throws  oif  the  decidua  with  a 
bloody  discharge.  This  spurious  labor  may  occur,  however,  at  any 
time,  and  always  does  occur  at  some  time  in  the  course  of  the 
gestation. 

Symptoms  of  Tubal  Pregnancy. 

To  some  extent  the  symptoms  of  tubal  pregnancy  have  been 
indicated.  In  some  cases  the  menstruation  is  uninterrupted.  The 
usual  signs  of  pregnancy,  such  as  pigmentation,  fulness  of  the  breasts, 

30 


494  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

and  morning  sickness,  may  be  present  or  absent.  During  the  first 
eight  weeks  the  ordinary  subjective  signs  of  pregnancy  usually  are 
absent.  Slight  uterine  hemorrhages  may  occur  at  irregular  intervals 
from  the  beginning.  Colicky  pains,  probably  due  to  uterine  contrac- 
tions, appear  toward  the  end  of  the  second  month,  and  are  apt  to 
continue  at  irregular  intervals  throughout  the  whole  period  of  gesta- 
tion. The  signs  of  interstitial  pregnancy  are  much  like  those  of 
normal  uterine  gestation.  This  is  explained  by  the  nearness  of  the 
gestation-sac  to  the  endometrium. 

When  tubal  pregnancy  goes  on  beyond  the  fourth  month  the  ex- 
ternal sign  of  asymmetrical  enlargement  in  the  abdomen  begins  to 
appear.  The  pressure-symptoms  are  much  like  those  of  uterine  preg- 
nancy. In  tuboligamentous  pregnancy  there  is  exaggerated  pressure 
on  the  pelvic  organs.  Finally  the  usual  signs  of  foetal  life  are  present, 
and  in  the  latter  mouths  of  tubal  pregnancy  painful  foetal  move- 
ments are  common. 

The  pains  of  spurious  labor  resemble  those  of  normal  parturition, 
and  are  sometimes  very  deceptive.  They  may  be  slight  or  severe. 
Cases  are  recorded  in  which  they  continued  for  days  and  even  weeks, 
or  recurred  irregularly  for  long  periods.  Cases  have  been  reported  in 
which  the  sac  ruptured  into  the  vagina  at  the  time  of  spurious  labor 
and  the  child  was  produced  by  the  natural  passage.  Rupture  into  the 
intestine  and  expulsion  of  the  foetus  through  the  bowel  have  been 
reported.     This  could  occur  only  in  the  earlier  weeks. 

Pelvic  Hsematocele  a  Result  of  Tubal  Pregnancy. — Pelvic 
hsematocele  is  an  accumulation  of  blood  in  the  pelvis  consequent  upon 
rupture  of  a  blood-vessel ;  in  rare  instances  it  may  be  due  to  trauma- 
tism or  to  rupture  of  a  vessel  from  disease  of  the  vessel,  but  in  the 
vast  majority  of  cases  it  is  the  result  of  tubal  abortion  or  tubal  rupt- 

EXPLANATION   OF   FlGtJRES   217   TO   223.^ 

FiGTJEE  217. — Side  view.  Pregnancy  complicated  by  hsematocele  of  both  broad 
ligaments ;  blood-clot  posterior  and  to  either  side  of  the  uterus,  crowding  the  cervix 
forward. 

Figure  218. — Eetro-uterine  hsematocele  extending  into  both  broad  ligaments,  the 
mass  on  the  one  side  rising  much  higher  than  on  the  other,  so  that  accumulation  of 
blood  feels  to  the  touch  like  two  distinct  masses  closely  set  together  and  sharply 
rounded  above  and  at  the  sides. 

Figure  219. — Front  view.  Hsematocele  of  left  broad  ligament  extending  anterior 
to  the  uterus ;  felt  as  a  hard  tumor  in  the  left  vaginal  vault  close  to  the  uterus ;  easily 
felt  through  the  vagina  and  in  the  left  inguinal  region. 

Figure  220. — Retro-uterine  hsematocele  lifting  the  peritoneum  high  out  of  the  cul- 
de-sac  of  Douglas,  and  extending  into  both  broad  ligaments.  Easily  felt  on  vaginal 
and  abdominal  palpation. 

Figure  221. — Front  view.  Hsematocele  in  both  broad  ligaments  extending  in  front 
of  the  uterus ;  tumor  larger  on  the  right  side  than  on  the  left,  and  divided  on  the  left 
into  two  segments.  The  mass  on  the  left  side  communicates  with  that  on  the  right, 
high  up  in  front  of  the  cervix.     Uterus  pushed  back  to  the  posterior  wall  of  the  pelvis. 

Figure  222. — Side  view.  Ketro-uterine  hsematocele,  not  extending  to  the  sides  of 
the  pelvis.  Mass  felt  between  the  uterus  and  rectum,  lifting  the  peritoneum  out  of  the 
cul-de-sac  of  Douglas  and  crowding  the  uterus  forward. 

Figure  223. — Front  view.  Hsematocele  of  the  left  broad  ligament,  lying  close  to 
the  uterus ;  easily  felt  by  vaginal  touch  and  by  palpation  over  the  left  iliac  region. 
Crowds  the  uterus  forward  and  to  the  right. 

» Redrawn  from  Kuhn. 


TUBAL  PREGNANCY. 


495 


FiGUBE  217. 


FiGrRE  220. 


Figure  219. 


FlGFRE  223. 


496  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

ure,  and  is  therefore  an  accident  of  tubal  pregnancy ;  in  fact,  the 
symptoms  of  tubal  abortion  and  rupture  are  those  of  pelvic  hsemato- 
cele.  There  are  no  premonitory  signs.  Small  hemorrhages  may  give 
rise  to  no  marked  subjective  symptoms ;  even  large  accumulations  of 
blood,  if  free  in  the  peritoneal  cavity,  may  cause  little  or  no  pain. 
When  the  blood  is  poured  out  into  confined  spaces,  such  as  the  space 
between  the  folds  of  the  broad  ligaments,  the  subjective  symptoms 
which  are  due  to  the  tearing  of  the  parts  are  distressing  and  over- 
whelming to  the  patient. 

There  is  sudden  and  excruciating  pain  all  over  the  abdomen,  and 
especially  about  the  pelvis ;  then  come  nausea,  vomiting  of  bile,  cold 
extremities,  bathing  of  the  skin  in  cold  sweat,  pinching  of  the  feat- 
ures, rapid  and  weak  pulse,  tenesmus,  and  irritability.  In  serious 
cases  the  shock  will  be  as  great  as  in  Asiatic  cholera;  the  pain  out- 
balances every  other  symptom.  The  tissues  are  being  literally  torn 
asunder.  Such  a  scene  can  never  be  forgotten.  The  woman  tosses 
to  and  fro  and  stains  the  bedclothing  with  vomit.  The  bloodless, 
pinched  features,  the  bloodshot  eyes  starting  from  their  sockets,  the 
twitching  of  the  facial  muscles,  the  clinching  of  the  fingers,  the  pierc- 
ing shriek,  the  agonized  bearing-down  movement,  as  if  the  woman 
would  drive  the  contents  of  her  body  from  her,  all  combine  to  make 
upon  the  memory  an  indelible  impression.  These  symptoms  may 
subside  and  convalescence  may  be  established,  with  absorption  of  the 
clot ;  or,  on  the  other  hand,  fresh  hemorrhage  and  acute  seneraia  with 
profound  collapse,  or  death,  may  occur  suddenly.^ 

The  symptoms  are  much  more  pronounced  in  tubal  rupture  than  in 
tubal  abortion.  If  the  abortion  is  complete — that  is,  if  the  ovum  and 
its  envelopes  are  thrown  out  completely — the  hemorrhage  may  be  com- 
paratively slight  and  may  be  walled  in  by  adhesions ;  under  such  cir- 
cumstances slow  recovery  may  take  place.  In  this  way  many  cases 
of  pelvic  hsematocele  recover  without  operation.  Such  results  are 
probably  more  common  in  the  very  early  stages  of  tubal  gestation 
than  generally  is  supposed.  In  fact,  many  such  cases  are  unrecog- 
nized. There  is,  indeed,  a  possibility  of  moderate  and  gradual  hemor- 
rhage without  pronounced  symptoms  In  a  very  large  propor- 
tion of  cases,  however,  the  abortion  is  incomplete,  and  a  portion  of 
the  ovum  or  its  envelopes  is  left  attached.  Repeated  hemorrhages, 
with  severe  abdominal  pain,  may,  after  days  or  weeks  of  suffering, 
unless  relieved  by  operation,  end  in  collapse.  If  the  progress  of  the 
case  is  more  rapid,  the  symptoms  closely  resemble  those  of  intestinal 
or  gastric  perforation  and  excessive  hemorrhage  combined.  Hsemato- 
cele at  first  may  be  unrecognized.  If  the  bleeding  be  excessive,  the 
early  sense  of  fulness  on  percussion  and  palpation  gives  way  later  to 
the  localized  signs  of  a  contracted  clot. 

The  hemorrhage  from  tubal  abortion  is  much  less  than  from  tubal 
rupture. 

As  already  stated,  hemorrhage  into  the  space  between  the  folds  of 
the  broad  ligament  is  confined,  and  therefore  limited.  If  the  force  is 
sufficiently  strong  to  cause  secondary  intraperitoneal  rupture — that  is, 

»  Adaptation  from  Emmet. 


TUBAL  PREGNANCY.  497 

rupture  from  the  interior  of  the  ligament  to  the  peritoneum— there 
will  be  great  danger  of  acute  hemorrhage  and  collapse.  If  the  blood 
is  confined,  vesical  and  rectal  tenesmus  and  other  symptoms  due  to 
tearing  and  pressure  may  overwhelm  the  patient. 

Diagnosis  of  Tubal  Pregnancy. 

In  the  early  period  of  tubal  pregnancy  there  are  no  certain  means 
of  diagnosis.  The  patient  may  have  noticed  no  irregularity  in  her 
physiological  life,  and  may  have  been  utterly  unaware  of  her  condition 
until  the  occurrence  of  rupture  or  abortion.  This  is  especially  likely 
to  be  the  case  when  the  abortion  or  rupture  occurs  very  early  after 
impregnation.  Usually,  however,  it  occurs  between  the  fourth  and 
ninth  weeks ;  during  this  time  certain  anomalies  already  mentioned, 
such  as  irregular  menstruation  or  pain,  may  have  attracted  attention 
and  led  to  the  discovery  of  an  enlarged  tube.  It  is  a  significant  fact 
in  diagnosis  that  tubal  pregnancy  often  occurs  after  long  periods  of 
sterility.  Such  sterility  therefore  is  somewhat  diagnostic.  The 
microscopical  finding  of  the  cast-oiF  decidua  together  with  the  history 
of  tubal  pregnancy  is  strongly  diagnostic.  In  the  later  periods  of 
gestation  many  of  the  usual  signs  of  pregnancy  are  modified  and  dis- 
torted by  abnormal  conditions. 

The  diagnosis  may  be  considered  with  reference  to  three  groups 
of  cases : 

I.  Late  cases  in  which  neither  tubal  rupture  nor  tubal  abortion  has 
occurred  and  in  which  gestation  is  progressing  or  has  progressed  to 
term. 

II.  Early  cases  in  which  neither  tubal  rupture  nor  abortion  has 
occurred. 

III.  Early  cases  in  which  tubal  rupture  or  abortion  has  occurred. 

I.  Late  cases  in  which  neither  tubal  rupture  nor  abortion  has 
occurred,  and  in  which  gestation  is  progressing  or  has  progressed  to 
term,  may  be  recognized  by  the  following  characteristics  : 

1.  Uterus  enlarged  to  the  size  of  two  months  pregnancy. 

2.  Formation  of  a  tumor  at  one  side  of  the  uterus,  which,  like 

the  uterus  in  normal  gestation,  gradually  increases  in  size, 
although  the  size  of  the  mass  does  not  always  correspond 
strictly  to  that  of  normal  gestation. 

3.  As  gestation  progresses  the  foetus  may  be  palpated  externally. 

Palpation  may  disclose  occasional  contractions  in  the  ges- 
tation-sac ;  the  foetal  heart-tones  become  distinct  at  about 
the  same  time  as  in  normal  pregnancy. 

4.  Intermittent  false  labor  at  nine  or  ten  months,  followed  by 

cessation  of  circulation  in  the  placenta  and  death  of  the 
child,  and  finally  by  marked  diminution  in  the  size  of  the 
tumor. 

5.  General  sepsis  from  absorption  of  decomposing  products  of 

gestation  in  most  cases. 

II.  Early  cases  in  which  neither  tubal  rupture  nor  abortion  has 
occurred  may  be  diagnosed  by  the  following  signs  : 


498 


TUMORS,   TUBAL  PEEONANCY,  MALFORMATIONS. 


Cessation  of  menstruation  for  one  or  two  months,  and  other 
signs   of  pregnancy,  such  as   nausea,  mammary  changes, 
and  venosity  of  the  vulva  and  vagina. 
Ovoid  mass,  corresponding  in  position  to  the  right  or  the  left 

tube — not  very  sensitive  to  pressure. 
Intermittent  contractions  of  the  mass — not  always  felt. 
Death  of  the  foetus  in  some  cases  without  tubal  rupture  or 
abortion  may  be  followed  by  absorption  of  the  amniotic 
fluid,  with  rapid  decrease  in  the  size  of  the  tumor. 
Early  cases  in  which  rupture  or  abortion  has  occurred  are 
characterized  by  symptoms  same  as  those  of  group  II.,  followed  by 
sudden  onset  of  extreme   pelvic  pain,  evidences  of  acute,  alarming, 
and  sometimes  fatal  hemorrhage  and  sudden  appearance  of  a  pelvic 
tumor — hsematocele. 


III. 


Differential  Diagnosis  of  Tubal  Pregnancy. 

The  following  outlines  will  enable  the  reader  to  distinguish  tubal  preg- 
nancy from  numerous  conditions,  for  which  it  sometimes  is  mistaken. 


Ruptured  tubal  pregnancy.    Hsematocele. 

1.  No  initial  liistory  of  infection. 

2.  Great  rapidity  of  pulse. 

3.  Temperature  at  first  subnormal,  later  may 
be  elevated. 

4.  Pain  excruciating,  but  subsides  after  few 
hours. 

5.  Symptoms  of  hemorrhage : 

o.  Sudden,  acute  aiieemia. 
6.  Weak,  rapid  heart. 

c.  Dyspnoea. 

d.  Sighing  respiration. 

e.  May  be  syncope. 

Ruptured  tubal  pregnancy.    Hxmatocele. 

1.  History  of  pregnancy. 

2.  Sudden  onset. 

3.  Hemorrhage  may  cause  collapse. 

4.  Temperature  normal  or  subnormal  at  first. 

5.  Usually  mass  soft ;  later  hard. 

6.  Fever  may  finally  follow  appearance  of 
hsematocele. 

7.  Uterine  decidua, 

8.  No  leucocytosis  at  time  of  rupture. 

Ruptured  tubal  pregnancy.    Hxmatocele. 

1.  Urgent  symptoms  at  onset. 

2.  Development  rapid. 

3.  Not  very  sharply  circumscribed. 

4.  Immobility  of  mass. 

5.  Signs  of  pregnancy  precede  formation  of 
mass. 

6.  Uterine  decidua. 

Ruptured  tubal  pregnancy.    Hxmatocele. 

1.  No  pre-existing  tumor. 

2.  History  of  pregnancy. 

3.  Tumor  not  smooth  and  tense. 

4.  Uterus  somewhat  enlarged. 

5.  Uterine  decidua. 

Tubal  pregnancy. 

1.  Before  rupture,  gestation-sac  harder. 

2.  Fluctuation  and  ballottement  absent. 

3.  Uterus  slightly  enlarged.  Tumor  separate 
from  uterus  and  crowds  it  to  opposite  side  of 
pelvis. 

4.  Unusual  history, 

5.  Tubal  abortion^  or  rupture  between  fourth 
and  ninth  week  usual. 

6.  Discharge  of  uterine  decidua  with  false 
labor-pains  occurring  usually  at  time  of  tubal 
abortion. 


Ruptured  pyosalpinx. 

1.  Initial  history  of  infection. 

2.  Pulse  not  so  rapid. 

3.  Rise  of  temperature  marked  from  onset. 

4.  Pain  less  intense  but  continuous. 

5.  Usually  absent. 


Pelvic  peritonitis  and  cellulitis. 

1.  History  of  infection. 

2.  Onset  less  sudden. 

3.  No  hemorrhage. 

4.  Temperatureelevated. 

5.  Usually  mass  hard  ;  later  may  soften. 

6.  Precedes. 

7.  Absent. 

8.  Always  leucocytosis  in  early  stages. 

Uterine  and  ovarian  tumors. 

1.  Absent. 

2.  Slow. 

3.  Mass  sharply  circumscribed. 

4.  Mobility  usual. 

5.  Absent  unless  complicated  by  pregnancy. 

6.  Absent. 

Hemorrhage  into  ovarian  cyst. 

1.  Pre-existing  tumor. 

2.  Absent. 

3.  Tumor  smooth  and  tense. 

4.  Not  so  much  enlarged. 

5.  Absent. 

Normal  pregnancy. 

1.  Uterus  softer. 

2.  Fluctuation  and  ballottement  later. 

3.  Tumor  is  enlarged  uterus. 


4.  Nothing  unusual  in  history 

5.  Does  not  occur. 

6.  Does  not  occur. 


TUBAL  PREGNANCY.  499 

Uterine  displacements,  pregnancy  in  one  liorn  of  a  bicornate  uterus, 
perforation  of  the  stomacli  or  bowel,  and  rupture  of  an  aneurism  have 
been  mistaken  for  tubal  pregnancy,  but  none  of  these  conditions  pro- 
duce the  symptom  group  outlined  in  the  above  paragraphs  on  Diag- 
nosis. In  cases  of  hsematocele  Huppert's  test  for  urobilin  will  give 
positive  evidence  of  the  absorption  of  blood  and  the  elimination  of  it 
by  the  kidneys. 

Prognosis  of  Tubal  Pregnancy. 

The  outlook  is  always  doubtful  and  serious.  Spontaneous  recovery 
is,  however,  not  uncommon.  In  former  times  pelvic  hsematocele 
was  not,  in  the  majority  of  cases,  recognized  as  related  to  tubal  preg- 
nancy, and  therefore  usually  was  treated  on  the  expectant  plan. 
Under  such  conditions  spontaneous  cures  were  frequent.  Our  knowl- 
edge of  the  true  pathology  and  the  consequent  greater  frequency 
of  operative  interference  do  not  change  the  fact  that  spontaneous 
recovery  often  will  occur  just  the  same,  even  though  the  name  of  the 
condition  has  been  changed  from  haematocele  to  tubal  pregnancy. 
However,  recovery  occurs  much  more  frequently  with  than  without 
operation  In  two  hundred  and  seventy-eight  cases  for  which  there 
had  been  no  operation,  collected  by  Schauta,  Martin,  and  Orthmann, 
one  hundred  and  eighty-seven,  or  a  little  over  two-thirds,  died  ;  while 
five  hundred  and  seven,  or  80  per  cent.,  of  six  hundred  and  thirty- 
six  cases  operated  upon,  survived.^ 

Viability  of  the  Child  at  Term. 

In  all  cases  of  ectopic  pregnancy  at  term  the  viability  of  the  child 
as  compared  to  the  life  and  welfare  of  the  mother  is  a  very  secondary 
matter.  Few  children  are  produced  alive,  and  fewer  still  survive 
many  days.  The  few  who  do  survive  are  physically  and  mentally 
inferior.  Harris  ^  collected  a  number  of  cases  of  living  children  of 
extra-uterine  pregnancies,  and  in  1895  reported  to  Orthmann  that  of 
fifty-seven  whose  histories  he  had  been  able  to  trace  only  five  survived 
their  second  year. 

Treatment  of  Tubal  Pregnancy. 

From  the  observations  already  made,  it  follows  that  the  treatment 
of  tubal  pregnancy,  as  a  general  rule,  will  be  operative.  The  safety 
of  the  patient  is  immeasurably  greater  if  the  diagnosis  is  made  and 
the  operation  performed  in  the  earlier  weeks,  before  the  time  of  tubal 
abortion  or  rupture.  Unfortunately  for  the  majority  of  cases,  the 
first  intimation  of  the  diagnosis   comes  with  one  of  tliese  accidents. 

The  treatment  will  vary  with  the  varying  conditions.  The  four 
possibilities  are : 

1.  That  the  diagnosis  has  been  made  before  the  time  of  rupture  or 
abortion. 

1  A.  Martin,    Die  Krankheiten  der  Eileiter,  1895. 

2  American  Journal  of  tlie  Medical  Sciences,  August-September,  1888. 


500  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

2.  That  rupture  or  abortion  has  just  occuiTed. 

3.  That  the  patient  has  survived  the  immediate  effects  of  rupture 
or  abortion,  and  that  gestation  has  ceased  with  death  of  the  foetus. 

4.  That  rupture  has  occurred,  but  the  tbetus  is  alive  and  gestation 
is  still  going  on. 

1.  Treatment  before  Rupture  or  Abortion. — The  tube  and  its 
contents  should  be  removed  immediately.  Only  by  this  means  can 
the  woman  be  protected  against  the  extreme  peril  of  continued  tubal 
gestation.  The  danger  of  the  operation  is  not  greater  than  removal 
of  the  uterine  appendages  under  other  circumstances;  the  technique 
is  the  same.  In  very  many  cases  tubal  pregnancy  is  unrecognized 
until  the  abdomen  has  been  opened  upon  the  diagnosis  of  a  supposed 
hydrosalpinx  or  pyosalpinx.  This  fact,  as  Penrose  saj's,  emphasizes 
the  value  of  the  rule  to  operate  for  all  gross  lesions  of  the  tube. 

2.  Treatment  Immediately  after  Rupture  or  Abortion. — The 
general  rule  is  to  operate  without  delay.  It  may  be  unwise  to  wait 
for  reaction  from  the  shock  and  hemorrhage,  for  hemorrhage  is  the 
very  indication  for  interference.  Indeed,  the  immediate  object  of  the 
operation  is  to  stop  the  hemorrhage. 

The  writer  has  recorded  two  cases  in  which  the  patients  were  in 
apparent  collapse,  and  for  this  reason  it  was  not  deemed  wise  to  operate 
unless  there  should  be  a  tendency  to  rally.  In  both  cases  slow  im- 
provement and  final  recovery  followed  the  operation.  A  few  months 
later  the  products  of  conception  disappeared  by  absorption.  These 
cases  show  that  without  0|)eration  the  prognosis,  even  in  the  most 
extreme  conditions,  is  not  hopeless. 

Operation. — The  abdomen  is  opened  as  described  in  Chapter 
VI.  The  tube  and,  together  with  it,  the  broad  ligament,  are 
grasped  and  pulled  into  the  wound  ;  two  pairs  of  strong  haemostatic 
forceps  are  placed  on  the  broad  ligament — one  on  the  infundibulo- 
pelvic  extension  of  it,  near  the  pelvic  wall,  the  other  close  to  the 
uterus  ;  this  will  control  the  ovarian  artery  at  its  point  of  entrance 
both  to  the  ligament  and  to  the  uterus.  Ligatures  are  substituted 
immediately  for  the  forceps,  the  tube  removed,  and  hsemostasis  secured 
as  described  in  Chapter  XXIII.  If  there  is  dead  space  between  the 
folds  of  the  broad  ligament,  it  may  be  obliterated  by  fine  buried  cat- 
gut sutures ;  or  if  too  large  to  be  sutured,  it  may  be  sutured  into  the 
abdominal  wound  and  drained  or  may  be  drained  through  the  vagina, 
as  explained  in  Chapter  XXVII.  for  drainage  of  intraligamentous 
myomata. 

The  free  infusion  of  normal  salt  solution,  two  or  more  pints,  by 
hypoderraoclysis,  preferably  under  the  breast,  or  the  introduction  of  it 
into  the  abdomen  before  closure  of  the  wound  as  described  in 
Chapter  VII.,  is  indicated  strongly.  This  solution,  which  may  be 
used,  according  to  the  indication,  before,  during,  and  after  the  opera- 
tion, has  turned  the  scale  for  recovery  in  many  a  desperate  case. 
If  the  hemorrhage  has  been  great,  Frankenthal  advises  direct  trans- 
fusion of  blood. 

3.  If  rupture  or  abortion  has  occurred,  and  the  patient  has  re- 
covered from  the  immediate  effects  of  it,  and  gestation  has  ceased  with 


TUBAL  PREGNANCY.  501 

death  of  the  foetus,  there  may  be  spontaneous  cure,  with  absorption 
and  disappearance  of  the  products  of  conception.  Under  these  favor- 
able conditions,  especially  if  there  be  continuous  gradual  improvement 
in  the  symptoms,  one  may  adopt  the  plan  of  watchful  expectancy. 
Frankenthal  says  :  "  Treat  conservatively  only  those  cases  seen  some 
time  after  primary  rupture,  when  you  are  reasonably  certain  of  the 
death  of  the  foetus,  when  the  alarming  symptoms  have  subsided,  and 
when,  presumably,  absorption  is  going  on."  Intraligamentous  rupture 
occurring  within  the  first  three  or  four  weeks  of  gestation  is  rather 
liable  to  be  followed  by  recovery  and  absorption.  One  must,  how- 
ever, be  prepared  to  operate  promptly  upon  the  least  evidence  of 
secondary  rupture  and  hemorrhage  or  upon  the  onset  of  infection. 
Even  in  uncomplicated  case's  of  this  third  division,  however,  it  is  per- 
missible and  possibly  safer  to  operate,  and  thereby  relieve  the  woman 
of  the  danger  incident  to  the  presence  of  a  dead  foetus  in  the  pelvis. 

Previous  to  the  fourth  or  fiftli  month  the  entire  gestation-sac  and 
its  contents  may  be  removed  usually  without  great  danger  of  fatal 
hemorrhage.  At  least  the  hemorrhage,  if  troublesome,  may  be  con- 
trolled by  ligature  of  the  ovarian  vessels,  or,  if  necessary,  of  the 
ovarian  and  uterine  vessels.  After  the  foetus  has  been  dead  for  some 
time  there  is  little  or  no  danger  of  hemorrhage  in  separating  the 
placenta. 

4.  If  gestation  has  advanced  beyond  the  fourth  or  fifth 
month,  and  the  child  is  living,  the  removal  of  the  foetus,  together 
with  the  placenta  and  gestation-sac,  is  practicable  in  only  a  small 
minority  of  cases,  and  then  only  in  the  hands  of  the  expert  ope- 
rator. The  conditions  favorable  for  this  radical  operation  are  found 
in  the  rare  pedunculated  tubal  pregnancies  already  mentioned,  in 
which  gestation  may  go  to  term  without  rupture,  and  in  other  rare 
cases  in  which  the  sac  can  be  isolated,  brought  through  the  wound, 
and  a  pedicle  formed,  or  its  attachments  separated  without  excessive 
hemorrhage.  Ligature  of  the  ovarian  and  uterine  vessels,  even  if 
practicable,  does  not  control  the  terrible  hemorrhage  which  at  this 
period  and  under  ordinary  conditions  invariably  follows  separation 
of  the  placenta.  The  surgeon  nmst  assume  the  great  responsibility 
of  a  decision,  when  the  abdomen  is  open,  whether  he  Avill  attempt 
removal  of  the  gestation-sac.  The  deliberate  attempt  to  remove 
it  has  resulted  many  times  in  uncontrollable  and  fatal  hemorrhage. 
In  opening  the  sac  the  operator  accidentally  may  incise  or  separate 
the  placenta  and  find  himself  face  to  face  with  a  most  formidable, 
if  not  unmanageable,  hemorrhage,  Compression  of  the  aorta  and 
ligature  of  the  uterine  and  ovarian  arteries,  if  promptly  and  skil- 
fully executed,  may  or  may  not  save  the  patient's  life.  In  the  vast 
majority  of  cases  in  which  gestation  is  in  progress  beyond  the  fourth 
or  fifth  month  the  operator  must  be  content  to  incise  the  sac,  remove 
the  foetus,  stitch  the  sac  to  the  abdominal  wound,  and  leave  the 
placenta.  J.  Bland  Sutton  proposes  to  close  the  sac  with  sutures 
instead  of  stitching  it  to  the  wound.  This  is  done  in  the  hope  that 
the  placenta  will  undergo  atrophy  or  absorption.  The  danger  of 
infection  in  a  sac  thus  closed  would  be  considerable.     The  more  usual 


502  TUMORS,   TUBAL  FBEGNANCY,  MALFORMATIONS. 

and  safer  plan,  therefore,  is  to  leave  the  placenta  and  establish  gauze 
or  tubular  drainage.  After  two  or  three  weeks,  when  the  placental 
circulation  has  ceased,  the  wound  may,  if  necessary,  be  reopened,  and 
the  placenta  taken  away,  but  the  more  common  and  approved  practice 
is  to  let  the  placenta  disintegrate  and  drain  away  as  debris. 

Some  operators  in  the  fourth  class  of  cases  prefer  to  delay  opera- 
tion until  after  term,  w^ien  the  child  has  died  and  the  placental  cir- 
culation has  ceased.  The  products  of  conception  may  then  be  removed 
entire,  with  the  minimum  danger  of  hemorrhage.  This  plan  neces- 
sarily involves  the  dangers  incident  to  the  continued  presence  of  an 
extra-uterine  foetus,  and  should  include  as  a  positive  requirement  that 
the  patient  remain  in  a  hospital. 

The  Abdominal  Versus  the  Vaginal  Route. — If  the  products  of 
conception  are  low  in  the  pelvis,  and  quite  accessible,  if  gestation  has 
not  passed  beyond  the  eighth  week,  and  if  the  tube  is  movable  so  that  it 
can  be  brought  out  readily  through  the  vaginal  wound,  it  is  permis- 
sible to  operate  by  the  vaginal  route.  If  the  gestation-sac  is  between 
the  folds  of  the  broad  ligament  and  the  child  has  been  for  some  time 
dead,  and  the  placental  circulation  therefore  has  ceased,  one  may  re- 
move the  products  of  conception,  unless  too  large,  and  drain  through 
the  vagina.  In  all  other  cases  the  difficulty  of  controlling  hemor- 
rhage through  the  vagina  is  too  great,  and  the  abdominal  route 
therefore  is  to  be  preferred.  The  difficulty,  not  to  say  impossibility, 
of  ligaturing  the  infundibulopelvic  ligament  through  the  vagina  is  an 
objection  to  the  vaginal  route.  Before  making  the  vaginal  incision  it 
is  sometimes  well  to  open  the  abdomen  by  a  short  incision,  so  that  if 
hemorrhage  occurs  no  time  will  be  lost  in  controlling  it  through  the 
abdominal  incision. 


CHAPTEE  XXXVII. 

EMBRYOLOGY    OF  THE  GENITALIA  AND  CONGENITAL 
MALFORMATIONS. 

EMBRYOLOGY. 

An  appreciation  of  the  embryology  of  the  genitalia  is  essential  to 
an  understanding  of  malformations  and  is  important  in  the  study  of 
pathological  growths.  The  various  phases  of  embryological  devel- 
opment cannot  be  made  clear  by  studying  the  human  embryo  alone, 
because  in  man  the  transitions  from  one  morphological  stage  to 
another  are  less  accessible  for  study  and  in  many  details  not  appar- 
ent; therefore  some  of  the  following  statements  are  derived  from  the 
embryology  of  lower  vertebrates.  The  development  of  the  reproduc- 
tive system  is  allied  so  closely  to  that  of  the  excretory  organs  that 
they  must  be  considered  together.  The  general  subject  may  be  skele- 
tonized as  follows  : 

DEVELOPMENT    OF    THE    WOLFFIAN    RIDGE. 

Early  in  embryonic  life  a  portion  of  the  mesoderm  (connective- 
tissue  layer)  known  as  the  intermediate  cell-mass  becomes  thickened 
and  projects  into  the  cavity  of  the  body  or  coelum  (later  peritoneal 
cavity).  This  projection  forms  a  ridge  which  is  concerned  in  the 
development  of  the  genito-urinary  system,  and  is  known  as  the 
Wol^an  ridge. 

DEVELOPMENT    OF    THE    GENITAL    RIDGE. 

On  the  inner  surface  of  the  Wolffian  ridge  a  secondary  projection 
(sexual  gland)  is  formed  which  develops  later  into  the  testis  in  the 
male  or  the  ovary  in  the  female,  and  is  called  the  genital  ridge. 

EMBRYOLOGY   OF    THE    EXCRETORY   ORGANS. 

In  connection  with  the  Wolffian  ridge  four  elementary  structures 
appear  as  follows : 

I.  Wolffian  ducts ;  one  on  each  side. 
II.  The  pronephros  or  primitive  kidney  in  connection  with  the 
Wolffian  duct ;  one  <m  each  side. 

III.  The  mesonephros  (Wolffian  body) ;  one  on  each  side. 

IV.  The  metanephros;  one  on  each  side. 

503 


504  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS. 


I.  Development  of  the  Wolffian  (Pronephric)  Ducts. 

The  pronepkric  ducts,  commonly  known  as  the  Wolffian  duets, 
begin  as  thickenings  of  portions  of  the  intermediate  cell-masses,  one 
on  each  side.  They  undergo  complete  development  in  man  and  have 
an  important  part  in  the  formation  of  the  urogenital  system.  The 
thickenings  project  as  solid  rods  of  cells  from  before  backward, 
beginning  near  the  region  of  the  heart  and  extending  toward  the 
cloaca — that  is,  the  lower  portion  of  the  intestine.  They  lie  imbedded 
in  the  substance  of  the  Wolffian  ridges.  Soon  after  their  formation 
each  of  these  cellular  rods  at  a  median  point  develops  a  cavity  which 
extends  in  both  directions  and  thus  converts  them  into  ducts,  the 
posterior  ends  of  which  invariably  open  into  the  cloaca.  As  already 
mentioned,  the  thickenings  from  which  the  Wolffian  ducts  arise  are 
of  mesodermal  origin,  but  in  early  development  the  posterior  ends  of 
the  ducts  fuse  with  the  overlying  ectoderm.  This  connection  is  tem- 
porary, and  while  it  lasts  gives  the  Wolffian  ducts  the  appearance  of 
having  originated  from  the  ectoderm ;  some  say  it  does  so  originate. 
The  occasional  persistence  of  this  connection  may  explain  the  pres- 
ence of  epithelial  structures  in  tumors  where  connective-tissue  struct- 
ures naturally  would  be  expected,  and  vice  versa. 


II.  Development  of  the  Pronephros. 

The  pronephros  develops  only  to  a  very  primitive  stage  in  the 
human  embryo  and  finally  is  resorbed,  although  traces  of  it  have 
been  observed  in  mature  man.  In  embryos  of  about  3  mm.  it  forms 
on  each  side  as  two  tubular  invaginations  of  the  epithelium  lining 
the  body-cavity  and  projects  into  the  substance  of  the  Wolffian  ridge. 
Each  of  these  tubules  ends  blindly  at  one  extremity  and  at  the  other 
opens  into  the  body-cavity.  The  pronephros  has  no  physiological 
significance  in  man,  but  there  are  some  pathological  growths,  for 
example,  of  the  kidney,  which  may  be  explained  as  persistence  and 
proliferation  of  some  of  the  cells  of  the  pronephros,  but  which  other- 
wise would  be  unexplainable. 

III.  Development  of  the  Mesonephros— Wolffian  Body. 

The  mesonephros  is  formed  by  a  number  of  tubules  running  trans- 
versely from  the  Wolffian  duct  toward  the  coelum  on  each  side  of  the 
body  and  penetrating  the  Wolffian  ridge.  These  tubules  have  a  tem- 
porary excretory  function  in  the  human  embryo,  and  in  some  verte- 
brates they  are  the  chief  permanent  renal  organs  throughout  life. 

IV.  Development  of  the  Metanephros. 

The  metanephros,  which  in  man  becomes  the  permanent  kidney, 
develops  from  an  outgrowth  which  begins  in  the  dorsal  aspect  of  the 


EMBRYOLOGY  OF  THE  GENERATIVE  ORGANS. 


505 


Wolffian  duct  and  in  the  tissue  surrounding  it.  In  the  embryo  of 
5  mm.  the  Wolffian  duct  presents  a  tubular  eminence  just  above 
the  point  of  its  insertion  into  the  cloaca  ;  this  outgrowth  becomes  the 
ureter.  The  extremity  of  the  ureter  branches  into  numerous  tubules, 
which  again  branch,  and  so  on  until  each  terminal  branch  ends  in  a 
distinct  vesicle  (primitive  vesicle).     The  vesicles  give  rise  to  several 


Figure  224. 


GLOMERULI  OF 
PRONEPHROS 


GENITAL  GLAND 

(ovary  or 
testicle) 


PRONLPHROS 


MUELLER- 
IAN    DUCT- 


DUCT  OF  NIESO- 
NEPHROS 


WOLFFIAN    DUCT 

(Gaertner's  duct) 


GLOMERULE 
OF  MESO- 
NEPHROS 


ARTERY 
MESONEPH^IOS 


ALLANTOIS 


: MESONEPHROS 

I  (Wolffian  body, 
itemporarj^  kld- 
:  iiey) 


METANEPH- 

Ros  (perma- 
nent kidney) 


Excrementary  organs  of  the  embryo,  showing  genital  gland,  pronephros,  mesonephros, 
metanephros,  aorta,  and  allantois. 


are 


tubules  which  become  the  uriniferous  tubules  of  the  kidney ;  thej 
coiled  upon  themselves  in  the  form  of  the  letter  S.  The  lower  por- 
tion of  each  tubule  is  surrounded  by  proliferating  cells  into  which  the 
renal  artery  branches  so  as  to  form  the  glomeruli  of  the  kidnev,  and 
the  walls  of  this  lower  portion  of  each  tubule  become  converted  into 
a  capsule  of  Bowman.     Additional  tubules  form  from  the  primitive 


506  TUMORS,    TUBAL  PREGNANCY,   MALFORMATIONS. 

FiGUBE  225. 


WOLFFIAN. 
DUCT 


MESONEPHROS 

(Wolffian  body, 
'  temporary  kid- 
Iney) 


Reproductive  organs  of  the  embryo :  lower  part  of  Mueller's  ducts  coalescing  to  form  the 
uterus  and  vagina.  Differentiation  of  sex  is  just  beginning  by  the  development  of  the  genital 
gland  into  an  ovary. 


Figure  226. 


WOLFFIAN 
DUCT 


DEVELOPING 
UTERUS 


MESONEPHROS 

;  (Wolffian  body, 
\  temporary  kid- 
'ney) 


GUBERNAC- 
ULUM  OF 
HUNTER 


Same  as  Figure  225.    Uterus  further  developed,  but  Mueller's  ducts  still  separable  ;  ovaries  and 
Fallopian  tubes  more  developed.    Wolffian  bodies  and  Wolffian  ducts  undergoing  atrophy. 


EMBRYOLOGY  OF  THE  GENERATIVE  ORGANS.  507 

Figure  227. 


OVARY  (gen- 
ital gland) 

FALLOPIAN 

TUBE  (Muel- 
ierian  auct) 


GAERTNER'S 

DUCT  (remains 

of  Wolffian 

duct) 


PAROVARIUM    OR 
EPOOPHORON 

(remains  of 
mesonephros  or 
Wolffian  body) 


PAROOPHORON 

(yellow  body 
of  Waldeyer; 


GUBERNAC- 
ULUM   OF 
HUNTER 


Same  as  Figure  226.  •  Each  rudimentary  Wolffian  duct  and  body  now  appear  as  the  paro- 
varium above,  and  the  paroophoron  below.  Uterus,  Fallopian  tubes,  and  ovaries  almost  fully 
developed.    Lower  part  of  Mueller's  ducts  persist  as  developed  uterus. 

vesicles,  giving  rise  to  a  large  number  of  glomeruli.  The  vesicles 
themselves  elongate  finally  and  form  the  collecting  tubules,  which 
open  separately  into  the  pelvis  of  the  kidney.  The  number  of  the 
primitive  vesicles  which  form  in  the  human  kidney  is  about  eighteen, 
and  each  one  corresponds  to  a  fully  developed  lobe. 


EMBRYOLOGY   OF   THE    GENERATIVE    ORGANS. 

In  close  developmental  relations  with  the  organs  already  described, 
which  are  mainly  excretory,  may  now  be  introduced  the  embryonic 
structures  which  have  more  especially  a  generative  significance ; 
they  are : 

I.  The  ducts  of  Mueller. 
II.  The  genital  ridge. 
III.  The  urogenital  sinus. 


I.  Development  of  the  Ducts  of  Mueller. 

When  the  mesonephros  (Wolffian  body)  has  reached  the  height  of 
its  development,  invaginations  form  in  the  peritoneum  cov^ering  the 


508  TUMORS,   TUBAL  PREGNANCY,   MALFORMATIONS. 

Wolffian  ridge,  and  these  invaginations  are  the  beginnings  of  the 
Muellerian  ducts,  which  are  imbedded  in  the  first  part  of  their  course 
in  the  substance  of  the  ridge  itself.  The  forming  ducts  become  dis- 
connected from  the  peritoneum  except  at  one  small  point,  and  con- 
tinue to  grow  as  two  solid  rods  of  cells  by  proliferation  of  their  ends. 
Presently  they  acquire  a  lumen  which  develops  throughout  their 
length. 

The  ducts  of  Mueller  are  situated  to  the  outer  side  of  the  Wolffian 
ducts,  except  in  the  lower  portion  of  their  course,  wdiere  they  are 
situated  between  them.  In  human  embryos  of  22  mm.  they  have 
attained  their  full  length,  and  finallv  thev  fuse  tojrether  at  the  lower 
end  to  form  the  uterus  and  vagina,  the  upper  portion,  however, 
remaining  separate  to  form  the  Fallopian  tubes. 

II.  Development  of  the  Genital  Ridge. 

As  already  stated,  one  portion  of  the  intermediate  cell-mass  on 
each  side  of  the  body  cavity  constitutes  the  "Wolffian  ridge,  and  the 
other  portion,  known  as  the  genital  ridge,  forms  the  sexual  gland — 
that  is,  the  ovary  in  the  female  and  the  testis  in  the  male.  The 
epithelial  cells  of  that  region  assume  a  high  columnar  form  and  grew 
several  layers  thick,  the  connective  tissue  beneath  proliferating  at  the 
same  time  so  as  to  form  a  distinct  elevation  or  ridge.  This  thickened 
epithelial  layer  (germinal  epithelium  of  the  ovary)  is  concerned  in  the 
formation  of  the  egg  cells.  Some  of  the  cells  of  the  germinal  epi- 
thelium are  seen  to  be  larger  and  more  spherical  than  others  ;  these 
are  the  primordial  ova  out  of  which  develop  the  sexual  glands. 


III.  Development  of  the  Urogenital  Sinus. 

The  terminal  portion  of  the  intestinal  canal  is  called  the  cloaca ;  it 
persists  as  a  common  opening  for  the  intestinal  and  the  urogenital 
system  until  after  the  fifth  week  of  foetal  life ;  the  allantoic  duct 
(allantois)  opens  into  it.  The  upper  portion  of  the  allantois  enlarges 
and  becomes  the  bladder,  while  the  lower  portion  remains  narrow. 
Into  the  lower,  narrow  portion  open  the  ducts  of  Mueller,  one  on  each 
side.  The  junction  of  the  Muellerian  ducts  with  the  narrow  portion 
of  the  allantois  divides  the  latter  into  two  parts  ;  the  part  above  the 
junction  represents  the  urethra,  while  the  part  below  is  the  urogenital 
sinus.  The  urogenital  sinus  forms  the  vestibule  in  the  female,  wdiile 
in  the  male  it  is  included  in  the  formation  of  the  urethra. 


DEVELOPMENT  OF  EMBRYONIC  STRUCTURES  INTO  ORGANS. 

The  pronephros  (primitive  kidney)  has  no  physiological  significance 
in  man.  The  development  of  the  metanephros  into  the  permanent 
kidney  in  man  has  Ijeen  described.  It  remains  to  consider  what 
becomes  of  the  Wolffian  ducts.  Wolffian  body,  the  ducts  of  Mueller^ 


DEVELOPMENT  OF  EMBRYONIC  STRUCTURES  INTO   ORGANS.    509 

the  genital  ridge,  and  the  nrogenital  tissues ;  the  following  explana- 
tions and  tabular  statements  accordingly  are  set  forth. 

What  becomes  op  the  Wolffian  Body  and  Ducts? 

In  the  eighth  week  of  the  female  embryo  the  Wolffian  body 
begins  to  undergo  atrophic  changes  and  is  resorbed  slowly,  except  a 
small  anterior  portion  which  persists  and  enters  into  the  formation  of 
the  sexual  organs,  the  resorption  being  much  more  extensive  in  the 
female  than  in  the  male. 

The  Wolffian  duct  and  the  remnant  of  the  Wolffian  body  give  rise 
to  the  following  homologous  structures  in  the  two  sexes  : 


In  the  embryo. 

1.  Wolffian  duct. 

2.  Wolffian    body,    anterior 
(sexual)  portion. 

3.  Wolffian    body,      inferior 
portion. 


In  the  adult  female. 

1.  Duct  of  Gaertner. 

2.  Parovarium  (epoophoron). 

3.  Paroophoron. 


In  the  adult  male. 

1.  Vas  deferens. 

2.  Epididymis. 

3.  Paradidymis  (organ    of 
Giraldes). 


At  the  lower  middle  part  of  the  Wolffian  duct  is  an  offshoot,  the 
gubernaculum  of  Hunter,  which  passes  through  the  canal  of  Nuck, 
and  which  by  contracting  draws  the  parovarium,  and  with  it  the 
ovary,  down  to  its  normal  location  in  the  posterior  fold  of  the  broad 
ligament.  The  contraction  of  this  cord  tlierefore  is  concerned  with 
the  descent  of  the  ovary.  In  rare  cases  this  contraction  is  so  excessive 
as  to  draw  the  ovary  through  the  canal  of  Nuck,  and  thereby  to 
produce  a  serious  displacement  of  the  ovary. 

The  Parovarium  (Epoophoron,  Organ  of  Rosenmueller). 

The  paroophoron  is  a  remnant  of  the  anterior  portion  of  the  Wolf- 
fian body,  and  is  situated  between  the  ovary  and  the  Fallopian  tube 
in  the  folds  of  the  broad  ligament ;  it  consists  of  a  number  of  tubules 
which  o])en  into  Gaertner's  duct,  this  duct,  as  shown  in  the  above 
table,  being  a  remnant  of  the  Wolffian  duct. 

Paroophoron  (Yellow  Body  of  Waldeyer). 

The  paroophoron  is  a  remnant  of  the  inferior  portion  of  the  Wolf- 
fian body,  is  situated  between  the  folds  of  the  broad  ligament  near  the 
uterus,  and  is  composed  of  a  number  of  small  blind  tubules  connect- 
ing with  one  another. 


What  becomes  of   the  Ducts  of  Mueller  ? 

The  Muellerian  ducts  in  the  male  become  rudimentary ;  in  the 
female  they  form  the  Fallopian  tubes,  uterus,  and  vagina. 

The  homologous  structures  in  the  two  sexes  developed  from  the 
ducts  of  Mueller  are  as  follows  : 

31 


510 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


Duct  of  Mueller.     In  the  embryo. 

1.  Upper  extremity. 

2.  Middle  ununited  portion. 

3.  Lower  united  portion. 


Duct  of   Mueller.    In  the  adult    Duct  of  Mueller.    In  the  adult 
1  male. 


female. 

1.  Fimbriated  extremity  of 
Fallopian  tube  (the  hydatid  of 
Morgagni  as  usually  desig- 
nated in  the  female  is  a  vesicle 
attached  to  one  frimtaria). 

2.  Fallopian  tube. 


3.  Uterus  and  vagina. 


1.  Hydatid  of  Morgagni. 


2.  Cornua  uteri  masculini 
(usually  absent,  sometimes 
rudimentary). 

3.  Uterus  masculinus  (rudi- 
mentary and  in  close  connec- 
tion with  the  prostate  gland). 


What  becomes  of  the  Genital  Eidge? 

The  structures  originating  ia  the  genital  ridge  in  both  sexes  are 
developed  as  follows : 


Genital  ridge  in  the  embryo. 

Germinal  epithelium  of  the 
genital  ridge. 

Jfesoblastic  portion  of  the 
genital  ridge. 


Genital  ridge  in  the  adult  female. 
Graafflan  follicles. 

Stroma  of  the  ovary. 


Genital  ridge  in  the  adult  male. 

Epithelium  of  the  seminifer- 
ous tubules. 

Connective  tissue  of  the 
testicle. 


What  becomes  of  the  Urogenital  Sinus  and  Neighboring 

Steuctuees? 
In  this  connection  the  student  is  referred  to  Figures  234-238  and 
the  accompanying  text. 


Urogenital  sinus  in  the  embryo. 

1.  Upper  portion  of  the  uro- 
genital sinus. 

2.  Lower  portion  of  the 
urogenital  sinus. 

3.  Epithelial  involutions  of 
sides  of  urogenital  sinus. 

4.  Genital  eminences  and 
folds  (neighboring  structures 
on  both  sides  of  urogenital 
sinus). 

5.  Integument  on  either  side 
of  orifice  of  urogenital  sinus. 


Urogenital   sinus    in    the    adult 
female. 

1.  Urethra. 

2.  Vestibule. 

o.  Glands  of  Bartbolini. 
4.  Clitoris  and  nymphse. 


5.  Labia  majora. 


Urogenital    sinus    in    the    adult 
male. 

1.  Upper  prostatic  portion 
of  urethra. 

2.  Lower  prostatic  portion 
of  urethra  and  membranous 
portion  of  urethra. 

3.  Cowper's  glands. 

4.  Penis. 


5.  Scrotum. 


DIFFERENTIATION    OF    SEX. 

From  the  foregoing  paragraphs  and  tables  it  will  be  seen  that  if 
the  genital  ridge  develops  into  an  ovary  the  result  will  be  a  female; 
if  into  a  testicle,  the  result  will  be  a  male. 

On  one  hand,  along  with  the  differentiation  of  the  genital  ridge 
into  an  ovary,  the  Muellerian  ducts  develop  into  Fallopian  tubes, 
uterus,  and  vagina,  while  the  Wolffian  ducts  and  body  atrophv,  leav- 
ing behind  only  rudimentary  structures.  On  the  other  hand,  along 
with  the  diiferentiation  of  the  genital  ridge  into  a  testicle,  the  reverse 
happens— that  is,  the  INIuellerian  ducts  atrophy  and  the  Wolffian  ducts 
and  Wolffian  body  become  important  male  organs — epididymis  and 
vas  deferens. 

The  development  of  the  external  genitalia  follows  the  same  lines 
in    both    sexes,    except   development    in    the    male   is   more  exten- 


CONGENITAL  MALFORMATIONS.  511 

sive  than  in  the  female,  being  arrested  in  the  female  with  the 
formation  of  the  clitoris,  nymphse,  and  labia  majora,  but  going  on  in 
the  male  to  the  development  of  the  penis  and  scrotum.  In  one  sense 
the  clitoris  embryologically  may  be  regarded  as  an  undeveloped  penis 
and  the  labia  as  an  undeveloped  scrotum. 

CONGENITAL  MALFORMATIONS. 

Malformations  may  be  due  to  arrested  development  or  to  excessive 
development.  In  the  first  class  of  anomalies  we  have  the  malforma- 
tions due  to  the  persistence  of  embryonal  conditions  ;  the  second  class 
includes  the  hypertrophies  and  multiplications  of  otherwise  normal 
organs  and  tissues. 

The  subject  should  be  studied  in  connection  with  the  first  part  of 
this  chapter  on  embryology. 

MALFORMATIONS  OF  THE  OVARIES. 

Malformations  of  the  ovaries  consist  mainly  in  lack  of  develop- 
ment or  in  excessive  development.     The  principal  anomalies  are  : 

Accessory  or  constricted  ovaries. 

Supernumerary  ovaries. 

Absence  of  the  ovaries. 

Rudimentary  ovaries. 

Congenital  hypertrophy  of  the  ovaries. 

Congenital  displacement  of  the  ovaries. 
Accessory  Ovaries  are  found  in  a  small  percentage  of  autopsies. 
They  are  always  of  small  size,  and  generally  are  connected  with 
normal  ovaries  by  a  pedunculated  or  sessile  attachment.  Two  or 
three  may  be  found  in  one  case.  They  are  usually  parts  of  the 
original  ovary  separated  during  late  foetal  life  by  the  constriction  of 
peritonitic  bands.  The  ovary  thus  may  be  divided  into  equal  halves 
or  may  be  divided  only  partially.  The  presence  of  accessory  ovaries 
may  account  for  pregnancy  after  both  ovaries  are  supposed  to  have 
been  removed. 

Supernumerary  Ovaries. — Only  one  authentic  case  has  been 
reported.^  This  was  a  third  ovary  situated  in  front  of  the  uterus 
in  direct  relation  with  the  bladder,  and  connected  to  the  uterus  by  a 
strong  ovarian  ligament.  This  ovary  was  twice  the  normal  size. 
The  two  other  ovaries  were  normal  and  of  equal  size.  There  was  no 
trace  of  peritonitis  in  the  neighborhood. 

Absence  of  the  Ovaries  is  a  rare  condition.  It  usually  is  asso- 
ciated with  imperfect  development  or  absence  of  one  or  more  of  the 
other  sexual  organs.  An  absolute  diagnosis  can  be  made  onlv  by 
autopsy,  for  the  ovary  may  be  present  in  an  abnormal  location  or  in 
a  partially  developed  state,  and  therefore  may  be  overlooked.  Absence 
of  one  ovary  is  apt  to  be  associated  with  absence  of  the  correspond- 
ing half  of  the  uterus  and  Fallopian  tube.  The  writer,  however,  in 
one  case  has  operated  for  the  removal  of  the  suppurating  right  tube 
and  ovary,  and  found  a  perfectly  developed  uterus  and,  so  far  as 
^  Winckel  in  Allbutt  and  Playfair,  System  of  Gynecologj\ 


512  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

could  be  discovered,  entire  absence  of  the  left  tube  and  ovary. 
There  was  only  a  slight  protuberance  at  the  left  uterine  cornu  to 
mark  the  point  where  the  tube  should  have  joined  the  uterus. 
Figure  228,  A.     August  Martin  reports  a  similar  case. 

Rudimentary  Ovaries  are  rather  uncommon.  They  are  of  small 
size,  and  the  Graafian  follicles  are  absent  or  rudimentary.  The  uterus 
may  be  normal  or  may  be  also  rudimentary. 

Congenital  Hypertrophy  of  the  Ovaries. — Excessive  growth  of 
the  ovary  has  been  recorded,  but  cannot  be  classed  strictly  as  a 
malformation.  It  has  been  attributed  to  hypersemic  or  inflammatory 
conditions  during  foetal  life. 

Congenital  Displacement  of  the  Ovary. — The  following  is  quoted 
from  Ballantyne  in  Allbutt  and  Playfair's  System  of  Gynecology: 
— ''  Non-descent  of  an  ovary  is  a  rare  but  not  unknown  anomaly. 
Bland  Sutton  has  reported  a  case  in  which  the  right  ovary  was 
adherent  to  the  lower  border  of  the  kidney  on  the  same  side,  and  I 
have  seen  a  case  in  the  newborn  infant  in  which  it  was  attached 
by  peritonitic  bands  to  the  caecum.  It  has  been  stated  that  it 
may  be  found  free  in  the  peritoneal  cavity.  Instead  of  non- 
descent,  there  may  be  dislocation  of  the  ovaries  downward  into 
the  inguinal  canal.  According  to  Puech,  congenital  inguinal  hernia 
of  the  ovary  is  much  more  common  than  acquired,  and  Zinnis  recently 
has  reported  an  instance  of  it ;  Bland  Sutton  states  that  he  knows 
of  no  case  in  which  the  ovarian  nature  of  the  herniated  body  has 
been  proved  by  microscopical  examination  conducted  by  a  competent 
observer.  Herniation  of  the  ovary,  which  may  be  unilateral  or 
bilateral,  is  associated  usually  with  displacement  of  the  Fallopian 
tube,  and  sometimes  with  malformation  of  the  uterus  and  malposi- 
tion of  the  kidney.  It  may  be  due  to  defective  development  of  the 
round  ligament  and  a  patent  condition  of  the  canal  of  Nuck." 

Clinical  Significance  of  Ovarian  Malformation. 

The  absence  of  one  ovary,  if  the  other  is  developed  perfectly,  does 
not  render  the  woman  sterile.  On  the  contrary,  her  reproductive 
functions  may  be  in  no  practical  respect  impaired.  If  both  ovaries 
are  rudimentary  or  absent,  sterility  is  inevitable.  There  is  usually 
wanting  in  such  cases  the  normal  development  at  puberty ;  there  may 
also  be  an  associated  faulty  general  nutrition,  a  weak  nervous  organ- 
ization, chlorosis,  and  not  uncommonly  a  growth  of  hair  on  the  face, 
especially  the  upper  lip.  The  individual  may  retain  the  general  phys- 
ical characteristics  of  infancy  and  childhood,  or  there  may  be  an 
apparently  full  development  of  the  extrapelvic  organs. 

Diagnosis  of  Ovarian  Malformation. 

The  diagnosis  of  ovarian  malformations  is  made  by  the  above 
signs  and  symptoms  and  by  the  recognition  on  conjoined  examination 
of  undeveloped,  absent,  accessory,  or  otherwise  anomalous  ovaries. 
Early  and  accurate  diagnosis  is  important,  for  only  by  this  means 


CONGENITAL  MALFORMATIONS.  513 

will  the  woman  be  saved  from  a  possible  long-continued  and  useless 
treatment  for  sterility.  It  is  often  impossible  to  say  that  an  appar- 
ently rudimentary  ovary  is  congenital,  for  it  may  have  been  subject 
to  atrophic  changes  consequent  upon  the  acute  infectious  diseases  of 
childhood. 

MALFORMATIONS  OF  THE  FALLOPIAN  TUBES. 

Malformations  of  the  tubes  are  analogous  to  those  of  the  ovary, 
and  are  therefore  as  follows  : 
Supernumerary  tubes. 
Accessory  tubes  and  ostia. 
Increased  length  and  excessive  convolution. 
Rudimentary  development. 
Absence  of  the  tubes. 

Supernumerary  Tubes  may  be  associated  with  supernumerary 
ovaries.     Only  a  few  cases  have  been  recorded. 

Accessory  Tubes  and  Ostia  are  not  uncommon.  As  many  as  six 
accessory  ostia  have  been  observed  in  one  tube.  The  anomaly  has 
no  definitely  recognized  significance. 

Increased  Length  and  Excessive  Convolution  of  the  tubes  may 
exist,  and  have  been  said  to  favor  tubal  pregnancy. 

Rudimentry  Development. — The  rudimentary  tube  is  usually  im- 
perforate, being  a  mere  fibrous  cord  with,  perhaps,  the  semblance  of 
an  open  ampulla  and  fimbriae.  The  corresponding  ovary  may  or  may 
not  be  also  rudimentary  or  absent.  The  accident  is  due  to  failure  of 
development  of  Mueller's  duct. 

Absence  of  the  Tube  pertains  more  frequently  to  one  than  to  both 
sides.  When  both  tubes  are  absent  the  uterus  and  ovaries  also  are 
usually  wanting.  Cases  have  been  recorded  in  which  the  tube  and 
kidney  on  the  same  side  were  absent.  Absence  of  one  tube  is  asso- 
ciated usually  with  lack  of  development  of  the  corresponding  side 
of  the  uterus — that  is,  with  uterus  unicornis. 

The  Clinical  Significance  of  malformations  of  the  tubes  is  much  the 
same  as  that  already  outlined  for  malformations  of  the  ovaries. 

MALFORMATIONS  OF  THE  UTERUS. 

The  developmental  defects  of  the  uterus  form  a  large  proportion 
of  the  genital  malformations.  They  may  be  ranged,  for  the  most 
part,  under  two  general  heads  :  1.  Those  due  to  imperfect  develop- 
ment of  Mueller's  ducts.  2.  Those  due  to  imperfect  blending  of 
Mueller's  ducts. 

Infantile  Uterus. — If  the  Muellerian  ducts  unite  but  do  not  con- 
tinue to  develop,  the  result  will  be  an  undeveloped,  infantile,  or  foetal 
uterus.  If  the  arrest  of  development  occurs  very  early  in  foetal  life, 
the  uterus  will  be  extremely  rudimentary.  It  may  consist  of  an  in- 
fantile cervix,  and  in  place  of  the  corpus  only  a  fibrous  cord  extend- 
ing from  the  site  of  one  Fallopian  opening  to  the  other.  If  arrest 
of  development  does  not  occur  until  after  birth,  the  uterus  will  be 


514  TUMORS,    TUBAL  PREGNANCY,  MALFORMATIONS. 

smaller  than  normal,  but  in  other  respects  not  strikingly  diflferent 
from  the  fully  developed  organ. 

The  anomalies  due  to  defective  blending  of  Mueller's  ducts  are 
numerous  and  frequent.  Nearly  every  degree  of  imperfect  fusion 
has  been  observed.     The  following  anomalies  are  due  to  this  cause. 

Double  Uterus. — The  most  extreme  anomaly  due  to  defective 
blending  is  the  double  uterus  (uterus  didelphys),  in  which  there  are 
two  complete  organs  lying  side  by  side,  each  Muellerian  duct  having 
formed  a  perfect  uterus  with  cervix  and  fundus,  but  with  only  one 
cornu,  one  Fallopian  tube,  and  one  round  ligament.  Either  of  these 
uteri  may  be  functionally  competent.  Pregnancy  and  parturition 
therefore  may  proceed  normally.  On  the  other  hand,  one  uterus  may 
be  rudimentary  or  imperforate.  If  the  imperforate  organ  is  functionally 
active,  it  may  become  distended  with  menstrual  blood  and  form 
hsematometra.     This  will  require   surgical  interference. 

Accessory  Uterus. — A  very  curious  and  rare  malformation  is  the 
uterus  accessorius.  In  this  condition,  besides  the  normal  uterus, 
there  exists  another  uterus  anteriorly,  between  it  and  the  bladder. 
In  one  case  a  third  uterine  lobe  was  found  attached  to  the  single 
cervix  of  a  bifid  uterus.  It  is  difficult  to  account  for  these  anomalies. 
The  assumption  has  been  made  that  the  accessory  organ  was  developed 
from  a  diverticulum  of  a  Muellerian  duct. 

Bicornate  Uterus. — Next  in  importance  to  the  double  uterus  is 
the  much  more  frequent  bicornate  uterus,  in  which  fusion  of  Mueller's 
ducts  has  occurred  lower  down  than  normal,  wath  the  result  of  pro- 
ducing a  Y-shaped  organ.  This  deformity  occurs  in  all  degrees.  In 
one  extreme,  the  septum  extends  the  whole  length  of  the  cervix  and 
gives  rise  to  a  double  os  externum.  Figure  229  ;  in  the  other  extreme 
the  two  cornua  may  be  separated  only  by  a  notch  at  the  fundus 
(uterus  cordiforrais). 

A  unique  case  occurring  in  the  author's  practice  in  which  the 
uterus  was  bicornate  is  perhaps  worthy  of  note.  The  patient,  thirty- 
five  years  of  age,  married  fifteen  years,  the  mother  of  two  children, 
and  a  sufferer  from  endometritis,  extreme  dysmenorrhoea  and  neuras- 
thenia. The  faulty  general  nutrition  was  thought  to  depend  largely 
upon  the  dysmenorrhoea.  The  patient  gave  a  history  of  having  been 
treated  for  a  long  time  and  in  many  ways,  the  treatment  having  in- 
cluded dilatation  and  curettage  of  the  uterus.  Examination  showed 
that  the  uterus  was  bicornate,  as  represented  in  Figure  230,  a  fact 
which  hitherto  had  not  been  recognized.  With  considerable  hesitation 
and  after  consultation,  it  was  decided  to  remove  the  two  horns  of  the 
bicornate  uterus,  and  the  operation  was  performed  as  shown  in 
Figures  230  to  233.  The  result  was  complete  restoration  to  health. 
Six  months  after  the  operation  the  general  nutrition  had  become  nor- 
mal, and  there  was  an  increase  in  weight  of  about  twenty  pounds. 
Although  supravaginal  hysterectomy  Avould  not  ordinarily  be  advo- 
cated as  a  proper  treatment  for  dysmenorrhoea,  yet  the  peculiarities 
of  this  rare  case  were  such  that  perhaps  the  operation  Avas  justifiable. 
At  any  rate  it  appears  to  have  been  justified  by  the  result.  The 
author  is  unable  to  find  any  record  of  a  similar  operation,  or  for  that 


CONGENITAL  MALFORMATIONS. 
Figure  228. 


515 


E 


F 

d^*^ 

^^^ 

iff/^ 

^^ 

W 

'^ 

'  -"SB 

p 

A.  Absence  of  the  left  ovary  and  Fallopian  tube,  with  full  development  of  the  other  genital 
organs.  Author's  case.  The  right  tube  and  ovary  were  removed  for  pyosalpinx  and  ovarian 
flbscGss  *  PGCOVGrv. 

B.  Fallopian  tiibe  with  accessory  ostium  on  right  side.  Fallopian  tube  with  accessory  tube 
on  left  side. 

C.  Double  uterus— i.  e.,  uterus  didelphys.  From  each  uterus  there  is  one  tube  and  one 
ovary.    The  vagina  is  also  double. 

D.  Uterus  septus  duplex.    Completelv  divided  uterus  and  incompletely  divided  vagina. 

E.  Ribbon-shaped  rudiment  of  uterus ;  rudimentary  Fallopian  tubes,  ovaries,  and  round 
ligaments  ;  vagina  well  developed. 

F.  Uterus  with  one  horn  (uterus  unicornis).  Left  horn,  ovary,  and  Fallopian  tube  very 
rudimentary. 


516 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


matter  of  the  removal  of  any  part  of  a  bicornate  uterus,  on  a  similar 
indication. 

Uterus  Septus. — In  this  anomaly  there  is  complete  division  of  the 
iiteras  into  two  cavities  by  an  anteroposterior  vertical  partition  or 
septum.  The  septum  may  be  complete  or  incomplete,  may  form  only 
a  ridge  on  the  interior  of  the  uterus,  may  extend  tlirough  the  cervix, 
or  it  may  be  confined  to  the  cervix  or  to  the  corpus.  There  mav  be, 
in  fact,  every  possible  variety  in  the  situation  or  completeness  of  the 
septum.     The  typical,  if  not   the  commonest,  form  has  two  lateral 

Figure  229. 


Double  uterus,  vagina,  and  vulva. 

cavities  for  both  corpus  and  cervix  uteri.  The  bicornate  and  septate 
uteri  have  a  similar  clinical  significance.  In  either  there  is  liable  to 
be  an  imperforate  condition  of  one  side  of  the  septum  or  the  other, 
with  resulting  hsematometra.  Menstruation  is  apt  to  be  frequent  and 
otherwise  abnormal,  and  parturition  to  be  embarrassed.  Utemis  sub- 
septus  signifies  an  imperfect  septum  and  consequent  partial  division. 
In  a  subseptate  uterus  malpresentations  are  prone  to  occur  and  the 
insertion  of  the  placenta  to  be  abnormal. 

There   is   in  the  above  varieties  of  malformations  of  the  uterus  a 


CONGENITA  L  MALFORMA  TIONS. 
FlGUKE  230. 


617 


Figure  231. 


Figure  232. 


Figure  233. 


Figure  230. — Uterus  Ijieoniis  unicoUis.  The  horns  (if  the  bicornate  uterus  are  continuous 
with  one  necli.  The  dotted  line  shows  the  line  of  incision  for  the  removal  of  the  two  horns 
of  the  uterus. 

Figure  231.— Same  as  Figure  230.  The  two  horns  of  the  uterus  have  been  removed  :  section 
of  Fallopian  tubes;  section  of  uterine  canal  made  through  the  two  horns  of  the  bicornate 
uterus     Black  and  white  lines  here  indicate  the  Y-shape  of  the  biccirnate  uterine  canal. 

Figure  232.— Same  as  Figure  231.  First  stitch  in  the  union  of  the  wound  made  by  removal 
of  the  two  horns  of  the  bicornate  uterus. 

Figure  233. — Same  as  Figure  232.  Uterine  part  of  wound  brought  together  from  side  to 
side,  and  united  by  continuous  suture.  End-to-end  approximation  of  the  broad  ligaments  and 
Fallopian  tubes  by  same  suture. 


518  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

complete  gradation  between  double  uterus  on  the  one  hand,  and 
uterus  septus  on  the  other. 

Uterus  Unicornis. — When  there  is  failure  of  fusion  and  more  or 
less  atrophy  of  the  duct  on  one  side,  so  that  only  one  horn  of  the 
uterus  is  well  developed,  or  only  one  exists,  we  have  the  single- 
horned  uterus,  or  uterus  unicornis.  The  kidney,  ureter,  ligaments, 
tube,  and  ovary  on  the  side  of  the  lacking  or  imperfect  cornu  are 
also,  as  a  rule,  rudimentary  or  absent.  The  rudimentary  horn  may 
be  hollow  or  solid  ;  if  the  former,  its  cavity  may  or  may  not  connect 
with  that  of  the  lower  part  of  the  uterus.  If  menstruation  takes 
place  in  the  closed  horn,  there  will  be  hsematometra,  and  the  normal 
progress  of  menstruation  on  the  other  side  will  lead  to  confusion  in 
the  diagnosis.  Bilateral  hsematometra,  both  horns  being  imperforate, 
would  give  rise  to  less  difficulty  in  the  diagnosis.     Figure  228,  F. 

Among  the  less  important  anomalies  of  the  uterus  are  the  following  : 

Defect  or  absence  of  the  vaginal  portion  of  the  cervix. 

Septate  os  externum,  with  no  trace  of  septum  above. 

Normal  development  on  one  side  and  defective  development  on  the 
other  ;  this  would  be  an  approach  to  a  unicornate  uterus. 

Flat  or  arched  fundus. 

Congenital  prolapse,  retroversion,  retroflexion,  or  anteflexion. 

Congenital  communication  between  the  endometrium  and  intestine 
or  bladder. 

In  a  remarkable  case  one  side  of  a  bipartite  uterus  is  said  to  have 
developed  on  the  exterior  of  the  body. 

Premature  Development  of  the  Uterus.— This  usually  is  asso- 
ciated with  similar  precocity  in  the  other  genital  organs.  Young 
girls  thus  may  menstruate  at  a  very  early  age  and  show  the  sexual 
development  of  mature  years. 

MALFORMATIONS  OF  THE  VAGINA. 

The  vagina,  in  common  with  the  uterus,  as  shown  above,  is  formed 
by  the  coalescence  of  Mueller's  ducts,  and  therefore  shares  largely  in 
the  malformations  of  that  organ.  Thus  the  double  uterus  and  the 
uterus  septus  may  be  associated  with  double  vagina. 

The  congenital  anomalies. of  the  vagina  are  : 
Double  vagina  (vagina  septa). 
Absence  of  vagina. 
Atresia  of  vagina. 

Vagina  Septa. — A  completely  double  vagina  having  two  canals, 
each  opening  into  an  external  vulva  of  its  own,  is  very  rare,  only  one 
case,  that  of  Katharin  Kaufmann,  having  been  reported.  In  this 
case  ^  the  pelvis  was  divided  by  a  peritoneal  fold  into  two  lateral 
cavities  ;  each  half  contained  a  bladder,  a  unicornate  uterus,  an  ovary, 
a  Fallopian  tube,  and  a  rectum.  The  spinal  cord  was  bifurcated  at 
the  level  of  the  third  lumbar  vertebra. 

The  ordinary  and  much  more  common  double  or  septate  vagina  is 
divided  into  two  passages  by  a  septum  above  the  vulva.     The  hymen 

•  Reported  by  Suppinger.    Allbutt  and  Playfair,  System  of  Gynecology. 


CONGENITAL  MALFORMATIONS.  519 

may  have  one  or  two  openings,  and  the  septum,  as  in  the  uterus,  may 
be  complete  or  partial. 

Double  uterus  and  double  vagina  often  coexist.  In  some  cases 
the  vagina  is  double  and  the  uterus  single,  with  the  os  externum  then 
opening  into  one  side  of  the  double  vagina.  The  other  side  ends  in 
a  cul-de-sac.  If,  under  these  conditions,  the  blind  passage  alone  be 
used  for  coition,  sterility  will  result.  In  other  cases  both  sides  may 
be  in  communication  with  the  uterus.  The  septum  may  be  so  imper- 
fect as  to  constitute  only  a  ridge  along  the  posterior  and  anterior  walls 
of  the  vagina. 

The  septum  seldom  divides  the  passage  into  exactly  equal  halves. 
Coitus  usually  is  confined  to  one  side.  In  case  of  uterus  imicornis 
the  vagina  may  be  very  small — in  fact,  of  only  half  size.  This  is 
because  one  of  Mueller's  ducts  has  failed  in  development  from  the 
uterus  down,  and  the  other  has  developed  only  on  its  own  side,  pro- 
ducing a  unilateral  vagina.  In  case  of  double  uterus,  or  uterus 
septus,  or  uterus  bicornis,  one-half  of  the  vagina  may  be  imperforate, 
with  resulting  accumulation  of  menstrual  blood  in  the  uterus  and 
vagina  on  that  side  (hsematometra  and  hsematocolpos).  Chapter 
XXXVIII. 

Aside  from  the  possibilities  of  sterility  and  hsematocolpos,  and  from 
the  uterine  conditions  which  may  be  associated,  a  vaginal  septum  is 
not  of  itself  a  very  serious  matter.  It  may  never  be  suspected  until 
parturition,  and  even  then  the  septum  may  be  destroyed  or  pushed  to 
one  side  by  the  passing  child. 

Complete  Absence  of  the  Vagina  usually  is  associated  with 
absence  or  defect  of  the  ovaries,  tubes,  and  uterus,  and  with  a  generally 
defective  sexual  organization.  If,  however,  the  defect  is  only  in  that 
part  of  Mueller's  ducts  which  forms  the  vagina,  the  uterus  and  tubes 
may  be  developed  normally.  Absence  of  the  vagina  then  will  lead 
after  puberty  to  retention  of  the  menstrual  products  and  the  necessity 
of  making  an  artificial  vaginal  passage  in  order  to  give  exit  to  retained 
menstrual  fluid,  and  otherwise  to  establish  the  physiological  integrity 
of  the  vagina.  Impregnation  and  parturition  have  taken  place  through 
a  vagina  thus  opened.  This  subject  will  be  considered  further  in  the 
next  chapter. 

Inflammatory  Atresia  of  the  Vagina  must  not  be  confounded 
with  congenital  absence  of  the  organ.  The  former  is  the  result  of 
adhesive  inflammations  which  may  be  foetal  and  involve  the  whole 
length  of  the  passage,  or  it  may  be  due  to  inflammation  occurring  in 
childhood  or  in  adult  life ;  see  Dissecting  Vulvovaginitis.  In  a  case 
of  adherent  vaginal  walls,  the  walls  when  separated  wherever  the  in- 
flammation has  not  been  destructive  will  retain  the  vaginal  mucosa. 
In  congenital  absence  of  the  vagina  the  mucosa  never  has  developed. 
There  is  only  connective  tissue  between  the  vesical  and  rectal  walls. 

Other  Anomalies  of  the  Vagina. — The  remaining  vaginal  anoma- 
lies are  rare  :  they  include  diverticula  and  communications  between  the 
vagina  and  other  organs,  such  as  the  rectum  and  urethra.  These  open- 
ings are  dependent  not  upon  defects  of  Mueller's  ducts,  but  rather  upon 
fcEtal  cloacal  conditions,  hereafter  to  be  described. 


520 


TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 


MALFORMATIONS  OF  THE  HYMEN. 

The  hymen  is  an  organ  of  variable  strength  and  form.  It  may  be 
annular,  notched,  fimbriated,  fenestrated,  cribriform,  crescentic,  thick, 
thin,  fragile,  tough,  or  vascular.  Some  of  these  conditions  are  normal, 
others  but  slightly  abnormal.  Complete  absence  is  extremely  rare,  if 
not  unknown.  Imperforation,  so-called,  is  a  condition  usually  due  to 
closure  of  the  end  of  a  Muellerian  duct,  and  is  therefore  in  no  sense  an 
abnormal  hymen. 

The  importance  of  these  anomalous  conditions  varies.  A  rigid 
hymen  makes  coitus  painful  or  impossible,  a  very  vascular  membrane 
may  lead  to  a  temporary  profuse  hemorrhage,  and  imperforation  gives 
rise  to  hsematocolpos,  or  in  extreme  cases  also  to  hsematometra,  and 
demands  operative  interference  ;  see  Congenital  Atresia  of  the  Genital 
Tract.  A  rigid  hymen  may,  after  marriage,  require  divulsion  or 
incision. 


MALFORMATIONS   OF  THE  VULVA  AND  ANUS. 

This  subject  becomes  relatively  simple  when  we  understand  the 
embryological  development  of  the  vulva  and  anus.  At  the  end  of 
the  sixth  week  of  foetal  life  the  tangible  differentiation  of  sex  begins, 
and  the  developmental  changes  which  then  normally  take  place  are 
shown  in  Figures  234  to  238.  The  student  is  referred  to  the  em- 
bryology of  the  genitalia  in  the  first  part  of  this  chapter. 

FiGUEE  235. 


A,„  ^i«™E  234  — 12,  rectum,  continuous  with,  All,  allantois  (bladder),  and,  M,  duet  of  Mueller 
vulva^  depression  of  skin  below  genital  prominence,  which  grows  inward  and  forms 

ront?!^^?'^^^n~T^®  ^'^Pression  has  extended  inward  and,  becoming  continuous  with  the 
rectum  and  allantois,  forms  the  cloaca,    a,  cloaca,    i^  bladder.     F,  vagina,    i^,  rectum! 

At  first  the  allantois  (which  forms  the  bladder),  the  rectum,  and  the 
Muellerian  ducts  (which  form  the  vagina,  uterus,  and  Fallopian  tubes), 
all  communicate  with  a  conmion  cavity,  but  do  not  at  this  time  open 
on  the  external  surface.  Presently  there  is  a  depression  in  the  skin 
which  opens  inward  to  this  cavity,  thus  forming  the  cloaca.  The 
cloaca!  opening  is  divided  now  into  two  parts  by  a  septum,  which 
later  develops  into  the  perineum.  The  posterior  portion  of  the  cloaca 
thus  divided  becomes  the  anus.     The  anterior  part  becomes  the  uro- 


CONGENITAL  MALFORMATIONS. 
Figure  236.  Figure  237c 


521 


Figure  236.— The  cloaca  is  becoming  divided  into  the  urogenital  sinus,  SU,  and  anus,  A.  by 
the  downward  growth  of  the  perineal  septum.  „,_    ^     .^     ^m     n      i,„„„ 

Figure  237.— The  perineum  is  completely  formed.  P,  perineum.  The  ducts  of  Mueller  have 
united  the  lower  portion  forming  the  vagina. 

Figure  238. 


The  upper  part  of  the  urogenital  sinus  has  contracted  into  the  urethra ;  the  lower  portion,  SU, 
now  becomes  the  vulva.   P,  perineum.    iJ,  rectum.    F,  vagina.     B,  bladder.    U.uretnra. 

Figure  239. 
G 


Figure  239.-Absence  of    cloacal    division.    Perineal    septum  wanting.    R,  rectum.    G, 
genital  canal.    B,  bladder.  .       ,        *  * 

Figure  240.— Absence  of  cloacal  division.    Perineal  septum  present. 

genital  sinns.     This  sinus  in  its  u])per  part  becomes  the  urethra,  and 
in  its  lower  part  the  vulva. 

The  anomalies  of  the  vulva  and  anus  are  : 

Atresia. 

Persistent  cloaca. 

Hypospadias. 

Epispadias. 

Infantile  vulva.  . 

Atresia  of  the  Urethra,  Vagina,  and  Anus.— The  cloacal  divi- 
sion by  which  the  urethra,  vas^ina,  and  anus  are  opened  and^  thereby 
prolonged  to  the  external  surface  may  fail  to  take  place.     This  failure 


522  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

will  result  in  complete  atresia  of  the  vagina,  urethra,  and  anus.  The 
perineal  septum  may  be  absent,  as  shown  in  Figure  239,  or  present, 
as  shown  in  Figure  240.  In  the  latter  case  the  opening  between  the 
rectum  and  the  urogenital  sinus  will  be  closed.  This  condition  of 
complete  atresia  has  been  observed  only  in  stillborn  foetal  monstrosi- 
ties. The  bladder,  urethra,  and  vagina — that  is,  the  urogenital  sinus 
— are  apt  to  be  distended  with  urine. 

Congenital  atresia  is  not  to  be  confounded  with  another  form  of 
vulvar  atresia  in  which  the  labia  have  become  adherent  from  inflam- 
mation.    This  adhesion  may  occur  before  or  after  birth.     The  adhe- 


FinrRE  241. 


Figure  242. 


Figure  241.— Building  of  a  urethra.  Author's  operation.  Congenital  absence  of  urethra. 
Black  and  white  dotted  lines  indicate  area  to  be  denuded  in  the  construction  of  a  new 
urethra. 

Figure  242.— Building  of  a  urethra.  Author's  operation.  Same  as  Figure  241.  Area  for 
construction  of  a  new  urethra  denuded.  Inner  margins  of  denuded  area  being  brought  to- 
gether by  continuous  catgut  sutures  so  as  to  unite  those  margins  over  the  sound,  which  has 
been  introduced  into  the  bladder  and  is  held  by  the  hand  of  an  assistant. 

sion  is  generally  incomplete,  so  that  urine  and  menstrual  fluid  can 
escape.  The  condition  has  been  designated  superficial  atresia  of  the 
vulva  ;  it  may  be  remedied  by  separating  the  labia,  either  by  divulsion 
or  by  cautious  dissection. 

Persistent  Cloaca. — In  this  anomaly  the  anus  practically  opens 
directly  into  the  vestibule  ;  there  is  no  perineum.  The  anomaly  is  a 
persistence  of  the  condition  in  Figure  236.  If  the  anal  sphincter  is 
also  deficient,  the  condition  is  a  pitiable  one.  When  there  is  control 
over  the  feces  an  operation  may  not  absolutely  be  needed  ;  but  Avhen 
there  is  incontinence  of  feces  it  is  always  advisable,  and  preferably 


CONGENITAL  MALFORMA  TIONS. 


523 


before  maturity.  The  usual  operation  has  been  to  pass  a  probe  into 
the  fistula  and  out  at  the  normal  position  of  the  anus,  then  split  up 
the  parts,  draw  the  rectum  downward  and  backward  to  the  angle  of 
the  incision,  suture  it  into  position,  and  close  the  gap  in  front.  A 
modification  of  this  operation  has  been  suggested  by  Buckmaster ;  in 
this  modification  the  new  anus  is  made  first  just  in  front  of  the  levator 
ani  muscle,  and  at  a  later  period  the  fibres  of  this  muscle  are  split  to 
make  a  sphincter. 

Hypospadias  in  the  female  is  a  defect  in  the  posterior  wall  of  the 
urethra,  or  in  extreme  cases  entire  absence  of  the  urethrovaginal 


FiGTJKE  243. 


Figure  244. 


A 

^ 

\ 

1 

1 

C 

d 

Figure  243.— Building  of  a  urethra.  Author's  operation.  Same  as  Figure  242.  Margins  of 
new  urethral  mucosa  united  over  the  sound  by  fine  continuous  chromic  catgut  suture.  The 
first  stitch  has  been  introduced  and  tied,  and  the  needle  is  being  introduced  for  the  second 
stitch  to  unite  the  outer  margins  of  the  denuded  area  for  the  completion  of  the  new  urethra. 

Figure  244.— Building  of  a  urethra.  Author's  operation.  Same  as  Figure  24o.  Sound  in 
position  as  in  Figures  242  and  243.  Last  stitch  of  a  continuous  suture  being  introduced.  This 
stitch  when  tied  will  complete  the  formation  of  the  new  urethra. 


wall,  with  resulting  incontinence  of  urine  as  in  a  vesicovaginal  fistula. 
The  malformation  is  a  continuation  of  the  foetal  condition,  shown 
in  Figure  236,  and  it  is  due  to  persistence  of  the  urogenital 
sinus.  The  lower  portion  of  the  allantois  has  failed  partially  or 
completely  at  development  into  a  urethra.  In  marked  cases  there 
is  incontinence,  but  in  slight  cases  there  may  be  control  of  urine. 
Hypertrophy  of  the  clitoris  is  apt  to  be  an  associated  defect. 
Sometimes  the  clitoris  may  be  large  enough  to  raise  the  question 
as  to  sex  of  the  individual.  A  condition  resembling  hypospadias 
may  result  from  traumatism-^that  is,  the  urethrovaginal  wall  may  be 


524  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

sargioally  divided,  or  may  slough  out  in  consequence  of  pressure- 
necrosis  following  labor.  Whatever  the  cause  of  the  condition 
may  be,  if  there  is  incontinence  of  urine,  a  plastic  operation  should 
be  made  to  construct  an  artificial  urethra.  Emmet  was  the  prin- 
cipal pioneer  in  this  operation.  His  method  was  to  utilize  the 
labia  minora  as  material  out  of  which  to  make  the  new  urethra.  He 
denuded  a  longitudinal  strip  on  the  inner  surface  of  each  labium,  and 
then  united  them  by  means  of  interrupted  sutures,  and  in  this  way 
was  successful  in  securing  more  or  less  retentive  power.  The  author 
has  for  several  years  employed  a  somewhat  different  method  with 
gratifying  results.  This  method  is  illustrated  in  Figures  241  to 
244. 

It  is  important  in  building  up  a  new  urethra  to  have  in  mind  three 
special  points  :  first,  to  introduce  the  sutures  over  a  rather  small  sound, 
for  the  urethra  will  usually  dilate,  and,  if  a  large  sound  is  used,  will 
therefore  finally  become  too  wide ;  second,  broad  areas  of  denudation 
should  be  made  on  each  side  so  as  to  produce  a  very  thick  urethro- 
vaginal wall,  for  this  wall  usually  grows  thinner  by  stretching  or 
absorption  and  therefore  should  be  quite  thick  to  begin  with ;  third, 
before  the  new  urethra  is  attempted  an  artificial  vesicovaginal  fistula 
should  be  made  midway  between  the  inner  extremity  of  the  urethra 
and  cervix  uteri,  so  that  during  the  healing  process  the  sutures  in  the 
new  urethra  may  not  be  disturbed  mechanically  by  the  outflow  of 
urine.  After  union  in  the  urethra  has  become  solid  the  fistula 
may  bS  closed  in  the  usual  fashion.  The  artificial  vesicovaginal 
fistula  should  be  made  as  described  in  the  treatment  of  cystitis, 
Chapter  XXIV. 

Epispadias  in  woman  is  a  defect  in  the  upper  wall  of  the  urethra, 
and  generally  is  accompanied  with  fissure  of  the  clitoris,  and  some- 
times also  with  fissure  of  the  symphysis  pubes  and  of  the  whole 
anterior  vesical  wall.  This  gives  rise  to  ectropion  of  the  bladder. 
Incontinence  of  urine  occurs  even  in  the  slighter  forms,  and  an  opera- 
tion is  required  to  restore  the  integrity  of  the  bladder-wall.  The 
labia  are  commonly  absent  in  extreme  forms  of  epispadias. 

Infantile  Vulva. — General  lack  of  development  of  the  vulva  and 
absence  of  the  labia  majora  and  minora  are  associated  commonly  with 
defects  of  the  internal  genital  organs  and  witli  a  generally  weak 
systemic  development,  and  often  coexist  with  chlorosis.  They  are 
not  an  absolute  impediment  to  impregnation,  but  may  be  to  parturition. 

MALFORMATIONS     OF    THE    NYMPHS,    CLITORIS,    AND 

PREPUCE. 

Hypertrophy  of  the  Nymphae  has  been  much  observed  in  the 
lower  races,  especially  among  the  African  tribes.  It  is  said  also  to 
be  found  frequently  in  connection  with  hypertrophv  of  the  mammse 
among  the  American  Indians.  See  Elephantiases,'  Chapter  XXV. 
The  nymphse  may  become  so  large  as  to  require  removal. 

Hypertrophy  of  the  Clitoris.— The  clitoris  will  be  recalled  as 


CONGENITAL  MALFORMATIONS.  525 

that   organ    in    the   female  which   corresponds   to    the  penis   in  the 
Figure  245.  Figure  246. 


Figure  247. 


Figure  248. 


rir.iTRE  2-15.— Circumcision  in  the  female.  Redundancy  of  the  prepuce  and  enlargement  of 
the  clitoris  in  a  masturbating- girl  cjf  eleven.  Appearance  of  prepuce  when  put  upon  the  stretch. 
The  scissors  are  dividing  the  prepuce  on  the  dorsum,  as  they  would  in  circumcision  of  the 
male  prepuce. 

Figure  246. — Same  as  Figure  245.  Right  half  of  the  divided  prepuce  hanging  loose  with 
forceps  attached.  Left  half  being  removed  with  scissors.  Right  half  also  to  be  removed  in 
same  way. 

Figure  247.— Same  as  Figure  24fi.  Redundant  portion  of  prepuce  all  removed.  Raw  sur- 
faces exposed.  Margins  of  wound  being  brought  together  by  means  of  interrupted  fine  catgut 
sutures. 

Figure  248.— Same  as  Figure  247.  Last  suture  is  being  introduced  completing  the  opera- 
tion. 

male.     Hvpertrophy   of  the  clitoris  may  be   congenital  or  acquired. 
Congenital  hypertrophy  is  associated  not  uncommonly  with  other  mal- 

32 


526  TUMORS,    TUBAL   PBEGNAyCY,   MALFORMATIONS. 

formations,  such  as  pseudohermaphrodism,  and  may  be  so  excessive 
as  to  give  the  clitoris  the  appearance  of  a  penis.  The  anomaly  occurs 
more  frequently  in  the  tropics  than  in  temperate  zones.  Congenital 
enlargement  of  the  clitoris  is  an  indication  for  removal  (clitorec- 
tomyj.  Acquired  enlargement  is  associated  usually  with  masturbation, 
but  unfortunately  excision  does  not  usually  put  an  end  to  the  habit. 
In  two  cases  of  uncontrollable  erotic  paroxysms  occurring  in  the  author's 
practice,  in  which  the  clitoris  appeared  to  be  the  storm  centre,  but  in 
which  there  had  been  no  masturbation,  excision  of  the  clitoris  was 
f  )llowed  by  relief.  This  operation,  clitorectomy,  since  the  career  of 
the  "  brilliant  and  blighted  Baker  Brown "  is  almost  obsolete ;  the 
indications  for  it  being  very  restricted. 

Acquired  hypertrophy,  usually  the  result  of  masturbation  in 
childhood,  does  not  produce  great  enlargement. 

Hypertrophy  of  the  Prepuce. — There  is  a  class  of  cases  occasion- 
ally observed  among  children  in  which  the  clitoris  is  enlarged  moder- 
ately and  surrounded  by  an  abundance  of  loose,  flabby,  redundant 
preputial  skin.  In  such  cases  the  causes  may  be  both  congenital 
and  acquired.  The  congenitally  hypertrophied  clitoris  and  redundant 
prepuce  are,  by  reason  of  their  size,  unduly  exposed  to  friction ; 
this  gives  rise  to  irritation ;  the  child  instinctively  rubs  or  scratches 
the  part  in  order  to  obtain  relief,  and  thus  gradually  forms  the 
habit  of  masturbation.  This  frequent  counterirritation  and  conse- 
quent congestion  are  then  in  themselves  additional  causes  of  enlarge- 
ment of  the  clitoris,  and  especially  of  redundancy  of  the  prepuce. 
The  child,  unless  relieved  of  the  local  irritation  and  taught  to  avoid 
all  friction  of  the  part,  soon  becomes  a  hopeless  neurotic.  The 
treatment  in  such  a  case  is  circumcision. 

The  technique  of  circumcklon,  which  closely  resembles  that  of 
circumcision  in  the  male,  is  set  forth  in  Figures  245  to  248.  In  the 
operation  the  same  careful  trimming  of  the  loose,  redundant  skin  is 
necessary  as  in  circumcision  of  the  male  child.  In  suitable  cases  the 
operation,  if  supplemented  by  positive  and  proper  moral  instruction 
and  by  judicious  hygiene,  may  be  followed  by  a  cure  of  the  unfor- 
tunate habit  and  by  relief  from  the  nervous  symptoms.  A  most 
important  factor  in  the  general  treatment  is  hygiene,  that  is,  a  non- 
nitrogenous  diet,  the  avoidance  of  sweets,  spices,  highly  seasoned  food, 
tea,  coffee,  and  stimulating  drinks. 

Adherent  Prepuce. — Adhesion  of  the  prepuce,  which  may  be 
congenital  or  acquired,  produces  the  same  reflex  nervous  symptoms  in 
the  male,  and  requires  the  same  treatment — that  is,  separation  of 
the  prepuce  from  the  glans  by  breaking  up  the  adhesions  or  by  inci- 
sion. In  some  cases  the  indication,  after  loosening  the  adhesion  is 
to  slit  up  the  prepuce  on  the  dorsum.  If  the  prepuce  is  not  so  re- 
dundant as  to  require  removal,  the  wound  as  in  the  corresponding  ope- 
ration in  the  male  may  be  reunited  by  a  line  of  union  at  right  angles 
to  the  line  of  incision. 


CONGENITAL  MALFORMATIONS.  527 

HERMAPHKODISM. 

If  we  use  the  word  herniaphrodisni  in  the  strict  sense,  to  signify  a 
combination  of  anatomically  and  functionally  perfect  male  and  female 
organs  in  one  individual,  a  typical  case  has  never  been  established 
satisfactorily.  The  condition  occurs  sometimes  in  the  higher,  but 
more  frequently  in  the  lower  vertebrates,  and  it  is  perhaps  possible 
in  man,  but  thus  far  has  not  been  demonstrated  by  the  necessary 
autopsy. 

The  cases  of  so-called  hermaphrodism  all,  or  nearly  all,  fall  under 
the  head  of  pseudohennajihrocUsm,  in  which  there  may  be  an  irreg- 
ular development  of  the  sexual  organs,  some  of  the  female,  others  of 
the  male  type,  but  with  a  decided  predominance  of  one  over  the  other. 
If  the  individual  is  really  a  female,  and  reseml)les  the  male,  the  mal- 
formation is  called  Gynandry  ;  if  the  male  resembles  the  female,  it  is 
Androgyny.  See  Figure  249,  which  is  presented  here  as  a  modifica- 
tion of  a  drawing  by  Zweifel. 

Gynandry. — There  are  two  classes  of  cases. 

In  one  class  the  breasts  approach  or  conform  to  the  male  tvpe. 
There  may  also  be  a  hairy  development  on  the  face  and  a  masculine 
voice,  contour,  and  appearance.  The  genitalia,  although  perhaps 
rudimentary,  are  yet  unmistakably  of  the  female  type.  There  may 
be  congenital  atresia  of  the  vagina  and  an  infantile  vulva,  but  the 
uterus  and  ovaries,  partly  or  fully  developed,  are  present. 

In  the  other  class  of  cases  the  hairy  development  and  masculine 
voice,  contour,  and  appearance  are  supplemented  by  one  or  more  of 
the  following  anomalies  : 

a.  Pronounced  hypertrophy  of  the  clitoris,  sometimes  to  the  size 
and  appearance  of  the  fully  developed  penis. 

6.  The  labia  minora  and  majora  may  be  fused  together  so  as  to 
obliterate  the  vulvar  entrance. 

e.  Ovarian  hernia  and  a  consequent  pouch  may  be  present,  resem- 
bling in  form  and  situation  a  scrotum  with  its  testicles.  The  uterus 
and  ovaries  are  developed  more  or  less  perfectly. 

Androgyny. — Most  of  the  cases  of  pseudohermaphrodism  occur 
in  individuals  M'ho  have  testicles,  and  are  therefore  essentially 
male.  There  are  several  forms  of  this  class,  of  which  three  are  given 
below. 

1.  The  mildest  form  is  that  in  which  the  breasts  approach  or  con- 
form to  the  female  type,  and  the  penis  and  testicles  are  correct  in 
form,  but  rudimentary. 

2.  An  interesting  subdivision  of  androgyny  includes  individuals 
M'hose  generative  organs  are  apparently  female,  exce]3t  that  they  have 
testicles  instead  of  ovaries,  these  glands  being  situated  in  the  abdomen 
or  in  the  inguinal  canal,  and  the  scrotum  being  absent.  The  clitoris, 
vulva,  vagina,  and  uterus,  more  or  less  imperfectly  developed,  are 
present.  Individuals  belonging  to  this  subdivision  are  usually  brought 
up  and  pass  as  women  throughout  their  lives. 

3.  The  most  numerous  suljdivision  is  that  of  hypospadic  men. 
There  is  an  imperfect,  diminutive  penis  held  down  by  a  bridle,  and 


528  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

having  the  appearance  of  a  large  clitoris.  The  pendulous  portion  of 
this  penis  is  imperforate.  The  hypospadiac  urethral  opening  corre- 
sponds in  situation  and  appearance  to  the  female  urethra.  The 
testicles  are  usually  in  the  abdomen  or  inguinal  canal,  and  the 
scrotum  is  wanting.  There  is  a  fissure  in  the  median  perineal  raphe 
— a  perineoscrotal  fissure.  The  development  on  either  side  of  this 
fissure  resembles  the  vulvar  labia.  These  individuals  have  the  female 
mammary  development,  usually  are  brought  up  as  girls,  and  in 
some  instances  have    discovered    the    mistake  only   after   marriage. 

FIC4TJRE  249. 


Pseudohermaphrodism  by  hypospadias  (male).  T,  testicles,  not  descended.  S,  symphysis 
pubis.  C,  undeveloped  penis,  resembling  large  clitoris.  B,  bladder.  V,  prostatic  vesicle 
(pseudovaginaj.    R,  rectum. 

Intercourse  may  be  possible  either  in  the  prostatic  vesicle,  see  Fig- 
ure 249,  or  in  the  dilated  urethra.  Some  of  these  monstrosities  have 
been  capable  of  coitus  both  as  men  and  women. 

The  importance  of  hermaphrodism  is  obvious.  As  a  clear  diag- 
nosis of  sex  in  doubtful  ca.ses  cannot  always  be  made  at  birth,  it  is 
suggested  that  in  cases  of  doubt  the  individual  should  be  brought  up 
as  a  boy.  This  course  will  cause  less  embarrassment,  and  in  the  vast 
majority  of  cases  will  prove  to  be  correct. 


Treatment  of  Hermaphrodism. 

The  treatment  of  hermaphrodism  is  limited  to  thofse  cases  in  which 
anatomical  defect  can  be  corrected  by  operative  measures.  The  labia, 
if  fused  together,  may  be  separated  by  l:.reaking  the  adhesions  or  by 


CONGENITAL  MALFORMATIONS.  529 

incision.  The  hypertrophic  clitoris  or  labia  may  be  remoyed  and  the 
\vounded  surfaces  coyered  by  a  plastic  operation. 

The  bridle  or  frsenura  holding  down  the  penis  in  androgyny  may 
require  an  operation  for  the  liberation  of  the  organ,  and  plastic  work 
for  the  covering  of  the  exposed  surfaces. 

Epispadias  and  pseudohermaphrodism  may  furnish  indications  for 
operative  measures,  and  if  so,  must  be  treated  in  each  case  according 
to  special  requirements. 


CHAPTER     XXXVIII. 

CONGENITAL  GYNATRESIA  WITH  RETAINED  MENSTRUAL 

FLUID. 

Atresia  in  the  genital  tract  of  a  menstruating  v/oman  is  apt  to 
result  in  retention  of  menstrual  fluid  above  the  point  of  obstruc- 
tion. The  fluid  thus  retained,  of  a  tar-like  color  and  consistence, 
contains  blood,  mucus,  and  epithelial  debris. 

Figures  250  to  261,  suggested  by  and  modified  from  a  scheme  of 
Sutton  and  Giles,  show  the  accumulations  of  menstrual  fluid  which 
may  take  place  above  the  various  possible  points  of  atresia  in  the 
uterus,  vagina,  or  vulva.  The  accumulations  come  under  one  of  the 
three  following  divisions  : 

1.  An  accumulation  in  the  vagina  will  take  place  above  the  point 
of  vaginal  or  vulvar  atresia,  and  is  called  hocmatocolpos. 

2.  An  accumulation  in  the  uterus  called  hcematometra  is  limited 
below  according  as  the  atresia  is  at  the  internal  or  external  os,  in  the 
corpus,  or  in  the  cervix  uteri.  A  distended  cervix  is  called  hsemato- 
trachelos. 

3.  The  uterus  having  been  distended,  the  blood  may  force  its  way 
into  and  distend  the  Fallopian  tubes,  producing  hcematosalpinx.  The 
fimbriated  extremity  in  such  cases  is  closed  by  adhesive  inflammation. 
Hsematosalpinx  due  to  retention  of  menstrual  blood  is  associated  usually 
with  hsematometra. 

Hsematocolpos  may  exist  alone  or  may  be  associated  with  hsemato- 
metra and  hsematosalpinx. 

The  Pathological  Results. 

The  pathological  results  are  primarily  those  of  pressure  upon  the 
mucosa,  and  distention  and  thinning  of  the  walls  of  the  dilated 
organs ;  this  leads  to  atrophy  of  the  mucosa  and  muscularis.  Sec- 
ondarily, there  may  be  infection  and  consequent  admixture  of  pus 
with  blood ;  the  conditions  may  then  be  termed  pyocolpos,  pyometra, 
and  pyosalpinx. 

Symptoms  of  Congenital  Gynatresia. 

The  symptoms  are  commonly  absent  until  puberty ;  at  this  time 
menstruation  first  begins  and  gives  rise  to  accumulations  of  men- 
strual blood.  The  young  girl  will  then  have  the  symptoms  of  monthly 
recurring  menstruation  called  the  molimen,  with  a  sense  of  superadded 
weight  aud  heaviness  due  to  accumulations  of  menstrual  fluid.  The 
sense  of  weight  will  increase  with  the  quantity  of  fluid,  and  in  cases 
of  extreme  hsematometra  will  become  excessive,  and  may  resemble 

530 


CONGENITA L   G  YNA  TRESIA. 


531 


labor-pains.  There  may  also  be  distressing  pressure  on  the  adjacent 
organs.  Suppuration,  if  present,  gives  rise  to  the  same  symptoms  of 
absorption  as  would  result  from  an  abscess. 


Diagnosis  of  Congenital  Gynatresia. 

The  physical  signs  will  reveal  a  fluctuating  elastic  tumor  corre- 
sponding to  the  seat  and  extent  of  the  accumulations.  The  tumor,  if 
in  the  vagina,  will  be  felt  most  distinctly  in  that  region,  and  may 
bulge  between  the  labia ;  if  in  the  uterus  and  tubes,  it  will  easily 
come  within  reach  of  the  external  hand  on  conjoined  examination, 
and  fluctuation  will  be  distinct  on  palpation  between  the  vagina  and 
hypogastrium.  The  distended  tubes  are  made  out  usually  to  either 
side  of  the  distended  uterus.      Conjoined  examination  with  the  left 


FiGURK  250. 


Figure  251. 


PiGUEE  250.— Atresia  at  the  vulva  first  causes  distention  of  the  vagina,  producing  haemato- 
colpos. 

Figure  251.— Atresia  at  the  vulva.    Hsematotrachelos  has  followed  hamatocolpos. 

index-finger  in  the  rectum  may  give  further  information.  The  finger 
in  the  rectum  and  the  sound  in  the  bladder  sometimes  will  define  the 
upper  limits  of  hsematocolpos. 

If  the  atresia  is  at  the  os  internum,  it  gives  rise  to  no  change  in  the 
form  of  the  cervix,  but  gives  to  the  corpus  uteri  the  appearance  of 
pregnancy. 

One  side  of  a  double  vagina  or  iderus  may  be  distended  and  the 
other  side  empty.  There  will  then  be  a  tumor  on  the  aflected  side 
and  lateral  displacement  by  pressure.  The  symptoms,  supplemented 
by  conjoined  examination  and  the  sound,  will  be  the  means  of  diag- 
nosis. The  groove  between  the  distended  and  empty  sides  may  be 
felt  on  rectal  touch. 

Hsematometra  is  distinguished  from  pregnancy  by  the  absence  of 


532  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

the  usual  signs  of  pregnancy,  especially  of  discoloration,  patulous  os 
externum,  and  vaginal  pulsation.     Haematocolpos  or  hsematometra  on 

Figure  252.  Figure  253. 


FiGtTRE  252.— Atresia  at  the  vulva  has  caused  hsematocolpos,  then  hsematotrachelos,  and 
then  hsematometra. 

Figure  253.— Atresia  at  the  vulva.  In  addition  to  the  conditions  in  Figure  252,  there  is 
added  haematosalpinx. 

Figure  254.  Figure  255. 


Figure  254. — Atresia  in  the  vagina  midway  between  the  vulva  and  os  externum,  causing 
heematocolpos  in  the  upper  half  of  the  vagina. 

Figure  255.— Same  as  in  Figure  254,  except  that  distention  of  the  whole  uterus  has  followed 
the  partial  hsematocolpos. 

one  side  of  a  double  uterus  or  vagina  may  lead  to  great  confusion. 
Conjoined  examination  and  the  history  of  the  case  will  serve  to  dis- 


CONGENITAL   GYNATRESIA. 


633 


tinguish  the  former  from  extra-uterine  pelvic  tumors,  and  the  latter 
from  abscess  or  cyst  of  the  vaginal  wall. 


Figure  256. 


Figure  257. 


Figure  256.— Atresia  at  the  os  externum  producing  a  hsematotrachelos.  Corpus  uteri  not 
yet  distended. 

Figure  257. — Atresia  at  the  os  internum  producing  haematometra.  Fallopian  tubes  may 
become  distended  later. 


Figure  258. 


Figure  259 


Figure  258.— Atresia  at  the  vulva  on  one  side  of  a  double  uterus  and  vagina,  causing  hsema- 
tocolpos  on  affected  side.  . ,         ,    ,  ,  , 

Figure  259.— Atresia  on  one  side  of  double  uterus  and  vagina  midvray  between  vulva  and 
OS  externum.    This  produces  partial  hsematocolpos  of  affected  side. 

The  greatest  care  in  manipulation  is  essential  lest  the  ^  sac  rupture 
and  discharge  its  contents  into  the  peritoneum,  or  the  fluid  be  forced 
through  the  Fallopian  tubes.     The  fluid,  however,  is  apt  to  be  sterile. 


534  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

Prognosis  of  Congenital  Gynatresia. 

Unless  relief  comes  from  operation,  the  thin  walls,  especially  of  the 
Fallopian  tubes,  may  rupture  and  set  up  peritonitis.  Suppuration 
raav  give  rise  to  the  phenomena  incident  to  pelvic  abscess.  If  the 
sac'  ruptures  into  the  intestine,  infection  and  death,  or  a  precarious 
recovery  may  follow. 

Treatment  of  Congenital  Gynatresia. 

The  treatment  is  free  incision  at  the  point  of  atresia,  evacuation 
of  accumulated  fluids,  ^vashing  out  and  drainage  of  the  cavity. 
There  is  in  these  cases  an  unexplained  and  excessive  liability  to  post- 
operative infection.  Extra  care  therefore  in  the  asepsis  before,  during, 
and  after  the  operation  is  imperative. 

FrouRE  260.  .  Figuee  261. 


Figure  260.— Atresia  on  one  side  of  double  uterus  and  vagina  at  vulva,  producing  hsemato- 
colpos,  hsematotrachelos,  and  hEematometra. 

Figure  261.— Atresia  on  one  side  of  double  uterus  and  vagina  at  os  externum,  producing 
hsematotrachelos  and  hsfematometra. 

Operations  for  Haematometra  will  vary  according  to  the  location 
and  extent  of  the  atresia.  In  some  cases  the  obstruction  is  slight  and 
easily  broken  by  a  sound  or  by  pushing  a  pair  of  blunt-pointed  scis- 
sors or  forceps  through  it,  and  spreading  the  blades  to  secure  the 
necessary  divulsion  and  dilatation.  The  canal  once  opened  should  be 
made  to  remain  patulous,  if  necessary,  by  immediate  free  incision  or 
dilatation.  The  atresia  may  be  at  the  internal  or  external  os,  or  the 
whole  cervical  canal  may  be  obliterated.  In  the  latter  case  it  is  some- 
times necessary  to  separate  the  bladder  from  the  uterus  as  in  anterior 
vaginal  section.  The  separation  does  not  necessarily  extend  into  the 
peritoneum,  but  should  be  carried  past  the  level  of  the  internal  os. 
The  anterior  wall  of  the  uterus  may  then  be  divided  longitudinally 
with  scissors  until  the  interior  of  the  corpus  is  reached  and  evacuated. 


CONGENITAL   GYNATRESIA.  535 

The  opening  thus  made  is  rendered  permanent  by  additional  incision, 
gauze  packing,  dilatation,  plastic  surgery,  or  all  these  combined. 

Hsematoraetra  may  occur  with  complete  or  nearly  complete  absence 
of  the  vagina.  See  Malformations  of  the  Vagina.  Under  these  con- 
ditions the  choice  of  procedure  is  between  : 

1.  Artificial  vagina. 

2.  Abdominal  hysterectomy  or  removal  of  the  uterine  appen- 
dages. 

1.  Artificial  Vagina  consists  in  separating  the  vesical  from  the  rectal 
plate  of  the  rectovaginal  septum  and  entering  and  evacuating  the 
uterus  through  the  canal  thus  made.  First  the  incision  is  made  freely 
from  side  to  side  through  the  vulvar  skin  ;  the  two  plates  of  the  recto- 
vesical septum  then  are  split  readily  apart  by  means  of  the  two  index- 
fingers,  which  easily  work  their  way  through  loose  cellular  tissue  to 
the  uterus-  The  uterus,  if  present,  will  be  recognized,  when  reached, 
by  its  relative  hardness  and  resistance,  and  sometimes  by  the  elasticity 
and  sense  of  fluctuation  of  retained  fluid,  and  may  be  opened  by 
means  of  the  sharp-pointed  scissors,  using  as  a  guide  the  aspirator 
needle  previously  introduced.  In  working  his  way  to  the  uterus,  the 
operator  may  avoid  entering  the  bladder  or  rectum  by  frequently 
introducing  the  finger  into  the  rectum  and  the  sound  into  the  bladder. 
Emmet  says  that  in  some  cases  the  new  vagina  when  it  heals  over  the 
glass  vaginal  dilator  is  covered  by  a  structure  not  altogether  unlike 
mucous  membrane,  and  that  after  healing  has  taken  place  the  frequent 
use  of  the  glass  dilator  will  keep  the  vagina  open.  The  writer's  ex- 
perience in  three  cases  personally  observed  is  that  no  such  membrane 
formed  ;  but  that,  on  the  contrary,  the  surfaces  were  entirely  cicatricial 
or  granulating  in  character. 

It  is  desirable  as  soon  as  the  vagina  has  been  opened  to  cover  it 
with  skin  flaps  dissected  from  the  external  genitals.  The  labia  minora 
frequently  are  utilized  for  this  purpose.  C.  K.  Fleming  has  pub- 
lished an  improvement  on  the  above  method.  Before  splitting  the 
rectovesical  septum  he  dissects  loose  a  long  wide  flap  composed  of 
the  hymen,  the  posterior  ends  of  the  nymphae  and  the  upper  part  of 
the  perineal  integument,  leaving  the  upper  part  of  the  flap  attached, 
and,  after  splitting  the  septum,  he  utilizes  this  flap  for  the  anterior 
vaginal  wall.  He  then  dissects  a  flap  from  the  labium  majus  on  one 
side,  leaving  the  lower  part  attached  for  the  posterior  vaginal  wall. 
After  splitting  the  septum  these  flaps  are  stitched  into  the  new 
vagina,  so  as  to  make  them  cover  the  raw  connective  tissue  surface 
of  it.  The  surfaces  exposed  by  the  loosening  of  the  flaps  then  are 
closed  by  means  of  fine  chromic  catgut  sutures.  This  operation  has 
been  permanently  successful. 

2.  Abdominal  Hysterectomy  or  Removal  of  the  Ovaries. — If  the  arti- 
ficial vagina  persistently  contracts  and  cannot  be  kept  open  as  an 
outlet  for  menstrual  fluid,  the  removal  of  the  uterus  would  be 
justifiable  and  preferable  to  removal  of  the  ovaries. 

Operations  for  Haematocolpos. — If  the  obstruction  be  only  a 
thin  membrane,  it  may  be  incised  freely  and  the  fluid  let  out  as  in 

1  Denver  Medical  Journal. 


636  TUMORS,   TUBAL  PREGNANCY,  MALFORMATIONS. 

h£eraatometra.  In  some  cases  there  is  absence  of  the  lower  and  dis- 
tention of  the  upper  part  of  the  vagina,  and  perhaps  also  of  the  uterus 
and  Fallopian  tubes.  Then  a  passage  must  be  made  carefully  to  the 
point  of  atresia  in  the  same  manner  as  for  opening  the  vagina  in 
hsematometra. 

An  operation  for  hsematocolpos  or  hfematometra  on  one  side  is  apt 
to  result  in  closure  of  the  opening  and  refilling  of  the  cavity.  For 
this  reason  it  is  important,  in  the  effort  to  secure  a  permanent  result, 
to  include  in  the  operation  the  free  division  of  the  septum  in  the 
vagina  and,  so  far  as  practicable,  in  the  uterus. 

In  haematosalpinx  the  tubes  usually  will  empty  themselves  through 
the  uterus  when  that  cavity  is  drained,  and  do  not  therefore  have  to 
be  removed  or  otherwise  disturbed. 

Hsematocolpos  and  hsematometra  may  be  the  result  of  traumatic 
as  well  as  of  congenital  atresia ;  the  principles  of  treatment  are  then 
the  same  as  for  the  congenital  anomaly — that  is,  to  let  out  the  con- 
fined fluid  and  adopt  measures  to  keep  the  passages  open. 

The  formation  of  an  artificial  vagina  in  cases  of  vaginal  atresia  and 
rudimentary  uterus  has  in  rare  instances  been  followed  by  develop- 
ment of  the  uterus  and  normal  menstruation,  and  may  therefore  pos- 
sibly result  in  maternity.  The  probability  of  such  a  result,  however, 
is  so  slight  as  to  discourage  the  operation. 

It  occasionally  happens  that  complete  atresia  of  the  vagina  and 
absent  or  extremely  rudimentary  uterus  are  not  discovered  until  after 
marriage.  In  such  a  case  maternity  being  clearly  impossible,  the 
question  may  arise  whether  or  not  the  formation  of  an  artificial 
vagina  is  justifiable.  The  operation  follows  the  technique  already 
laid  down  for  the  formation  of  artificial  vagina  in  cases  of  hsemato- 
metra. Cases  have  been  reported  in  which  after  the  operation  mar- 
riage was  happy,  the  woman  even  recovering  from  a  tendency  to 
melancholia,  and  experiencing  great  improvement  in  nervous  tone 
and  general  strength.  The  question  of  the  propriety  of  such  an 
operation  may  be  relegated  to  the  department  of  ethics  and  casuistry. 


PART  IV. 
TRAUMATISMS. 


CHAPTER    XXXIX. 

NON-PUERPERAL     INJURIES    OF    THE   VULVA,    VAGINA, 
AND    CERVIX  UTERI. 

INJURIES  OF    THE   VULVA. 

The  external  genitals  are  protected  from  violence  by  their  situation 
and  relations  to  the  surrounding  parts,  and  therefore  are  little  exposed 
to  external  traumatism. 

Etiology. — The  following  causes  of  traumatism  are  recognized  : 
1.  Falling  upon  a  sharp  substance.  2.  Self-inflicted  wounds  by  the 
insane.  3.  Violent  coitus.  4.  A  blow  or  fall  which  so  bruises  the 
soft  parts  against  the  sharp  edges  of  the  descending  ramus  of  the 
pubes  or  the  ascending  ramus  of  the  ischium  as  to  make  a  deep  cut. 
The  cut  may  appear  at  the  surface  or  may  be  subcutaneous. 

Symptoms. — The  symptoms  are  the  same  as  those  of  similar  injuries 
elsewhere.  Hemorrhage  from  the  abundant  vessels  about  the  vulva 
is  usual  in  wounds  of  that  region.  When  the  wound  is  external  the 
bleeding  may  be  alarming — even  fatal.  Great  subcutaneous  extrav- 
asation of  blood  may  occur  in  the  bruised  parts.  This  when  clotted 
forms  pudendal  hcematonia. 

Treatment. — Superficial  incised  wounds  should  be  treated  by 
suture.  Bleeding  points  should  be  ligatured  with  fine  catgut.  Deep 
punctured  wounds  are  treated  best  by  compresses,  which  serve  for 
dressings  and  to  control  hemorrhage.  Small  haematomata  may  dis- 
appear by  absorption  ;  if  too  large  for  absorption,  compresses  should 
be  applied  for  four  to  eight  days,  until  all  danger  of  hemorrhage  has 
passed.  Then  a  free  incision  should  be  made,  the  clot  turned  out, 
the  cavity  packed  with  aseptic  gauze  and  allowed  to  heal  from  the 
bottom.     Suppuration  is  treated  by  incision  and  drainage. 

INJURIES  OF    THE  VAGINA    AND   VAGINAL    PORTION   OF    THE 

CERVIX    UTERI. 

Injuries  of  the  vagina  and  vaginal  portion  of  the  cervix  uteri  of 
non-puerperal  origin  are  more  rare  than  injuries  of  the  vulva. 
They  may  result  from  violent  coitus  or  from  the  violent  application 
of  any  other  force.  The  control  of  hemorrhage  and  the  repair  of 
vaginal  wounds  follow  the  general  principles  of  surgery. 

537 


CHAPTER    XL. 

LACERATIONS    OF    THE    PERINEUM    AND    PERINEAL 

REGION. 

IxjUEiES  of  the  vaginal  outlet  and  pelvic  floor  caused  by  parturi- 
tion, and  usually  designated  as  lacerations  of  the  perineum,  are 
among  the  most  frequent  of  gynecological  lesions,  and  even  though 
the  importance  of  these  injuries  sometimes  may  be  overestimated,  the 
fact  is  undeniable  that  they  give  rise  to  many  serious  disorders  and 
inconveniences.  It  is  not  always  possible  to  avoid  the  accident,  but  it 
is  possible  to  recognize  it  when  it  occurs  and,  by  a  timely  operation, 
prevent  evil  consequences.  A  laceration  that  does  not  extend  into 
and  destroy  the  functions  of  the  sphincter  ani  muscle  is  incomplete. 
The  laceration  is  oomplete  if  the  sphincter  is  injured  sufficiently  to 
impair  its  functions — i.  e.,  if  the  patient  has  lost  power  to  retain  the 
contents  of  the  bowel. 


ANATOMY  OF  THE  PERINEUM  AND  PERINEAL  REGION: 

The  perineum  is  the   converging  point  where   many  of  the  most 
important   parts  of  the  pelvic   floor  come   together ;  these  parts  are  ; 

FicrEE  262. 


nr>mV1p^^^v.°^.i^H^°^-'^^^^•  --Bulbocavernous  muscle.  3.  Constrictor  vaeiiiEe  muscle.  4.  Tri- 
i;.^?n^r^Vnf  ^f,^i"  °-Transversuspejinei  muscle.  6.  Sphincter  ani  muscle.  7.  Fascia  of  the 
levator  am  muscle.    8.  Perineal  fascia.    9.  Levator  ani  muscle. 

the  bulbocavernosus  muscle ;  the  transversus  perinei  muscles,  super- 
ficial and  deep  fascia :  the  external  sphincter  ani  muscle  ;  the  inter- 
nal sphincter  ani  muscle  ;  and  the  levator  ani  muscle.     The  muscles 

533 


LACERATIONS  OB'  THE  PERINEUM. 


539 


are  surrounded  and  bound  together  by  deep  and  superficial  fascia ; 
the  fascia  in  some  places,  for  example,  in  the  triangular  ligament,  is 
quite  dense,  and  resisting.  All  the  perineal  muscles,  through  the 
medium  of  tendon  and  fascia,  are  directly  or  indirectly  strongly  con- 
nected with  the  pubic  bones.     The   muscles,  ligaments,  and  fasciae 


FiorRE  263. 


Right  side,  showing  vesicorectal  fascia. 

unite  in  the  perineum  to  form  a  diaphragm  which  fills  the  pelvic  out- 
let. Through  this  diaphragm  pass  the  lower  portions  of  the  rectum, 
anus,  vagina,  and  uretiira. 

FUNCTIONS  OF  THE  PEl^INEUM  AND  PEEINEAL  REGION. 

It  is  clear  from  the  foregoing  paragraphs  and  illustrations  that  the 
muscles,  fasciae,  and  ligaments  of  the  perineal  region  constitute  a  most 
essential  supporting  part  of  the  pelvic  floor.  They  surround,  bind 
together,  hold  in  position,  support  and  maintain  in  their  mechanical 
relations  the  terminal  ends  of  the  rectum,  vagina,  and  urethra.  The 
reader  is  now  prepared  to  take  exception  to  the  common  notion  that 
the  pelvic  organs  derive  their  support  from  the  small  fleshy  body 
called  the  perineum.  Another  false  idea  is  that  the  support  is  in  the 
nature  of  that  given  by  a  keystone  to  an  arch.  The  perineal  region 
and  perineal  body  do  not  give  support  in  the  sense  of  being  under  the 
pelvic  organs  and  holding  them  up  as  foundations.  They  are  an 
essential  and  integral  part  of  the  pelvic  floor,  and  as  such  contribute 
to  the  support  of  the  abdominal  organs  above.  The  perineal  muscles 
do  not  fix  the  parts  to  which  they  are  attached.  For  to  do  this  would 
require  continuous  activity  and  would  soon  exhaust  their  power,  and 
would  therefore  be  unphysiological.  They  serve  to  control  the  lower 
portions  of  the  rectum,  vagina,  and  urethra  in  the  performance  of  their 
functions. 


540 


TRAUMATISMS. 


The  importance  of  the  levator  ani  muscle  as  a  means  of  support 
has  been  overestimated  ;  on  this  subject  a  very  suggestive,  convincing, 
and  clear  statement  comes  from  William  W.  Browning,  of  Brooklyn. 
His  conclusions  are  as  follows  : 

"  1.  That  in  the  human  subject  it  belongs  to  the  class  of  rudimen- 
tary muscles. 

"  2.  That  the  weakness  of  its  origin,  as  well  as  the  direction  and 
the  insertion  of  its  fibres,  is  inconsistent  with  the  design  of  support. 

"  3.  That  it  is  unphysiological  for  a  muscle  to  furnish  a  continuous 
support. 

FiGrEE  264. 


Normal  relations  of  the  pelvic  organs,  showing  the  vaginal  walls  resting  on  the  perineal  body. 

"  4.  That  the  rectovesical  fascia  is  in  itself  sufficient,  when  intact, 
to  afford  the  required  support. 

"  5.  That  the  muscle  is  no  better  developed  in  the  female  (in  whom 
support  is  more  required)  than  in  the  male." 


LACERATIONS  OF  THE  PERINEUM. 

A  mere  rupture  in  the  perineal  body  where  certain  muscles,  fasciae, 
and  ligaments  of  the  pelvic  floor  converge  is  not  necessarily  very 


LACERATIONS  OF  THE  PERINEUM.  541 

significant.  If^  however,  the  injury  involves  the  rending  asunder  of 
these  supports,  especially  the  fascial  supports ;  if  they  are  so  divulsed 
as  to  lose  their  sustaining  power ;  and,  above  all,  if  they  are  torn  off 
from  their  pubic  attachments,  the  lesion  becomes  more  serious. 

Causes  and  Prevention. 

Relative  disproportion  between  the  ghild  and  the  perineal  outlet 
may,  unless  an  incision  is  made,  render  laceration  inevitable.  Among 
other  unpreventable  causes  are  rapid  labor  and  oedema  of  the  vulva. 
The  preventable  causes  and  the  means  of  protecting  the  perineum 
during  labor  are  laid  down  fully  in  works  on  midwifery.  If  during 
labor  rupture  seems  imminent,  it  is  better  to  divide  the  vulvar  ring 

Figure  265. 


Correct  incision  in  episiotomy.    Lines  B,  B  show  incorrect  place  for  incision. 

by  an  incision  known  as  episiotomy,  and  thereby  substitute  a  clean 
cut  in  another  direction  for  a  ragged,  lacerated  Avound,  which  per- 
haps might  involve  the  sphincter  muscle.  The  usual  method  of 
episiotomy  is  to  make  a  transverse  incision  through  the  middle  of 
the  labium  majus  on  each  side.  BB,  Figure  265.  The  objections 
to  these  incisions  are  that  the  rents  may  extend  still  further  in  the 
lateral  direction,  as  the  head  passes,  and  that  an  additional  fresh 
tear  may  occur  at  the  posterior  commissure  of  the  vulva,  making 
three  wounds,  all  in  awkward  directions.  A  single  incision  in  the 
direction  shown  by  the  scissors  in  Figure  265  is  preferable,  for  any 
further  tear  will  be  to  one  side  of  the  sphincter  ani  muscle  instead  of 
through  it. 

Complete   Laceration   through   the  sphincter   ani   muscle  entirely 

33 


542 


TRAUMATISMS. 


destroys,  the  retentive  power  of  the  bowel.  The  rupture  in  rare 
instances  occurs  subcutaneously  without  a  visible  break  in  the  cuta- 
neous surfaces  around  the  anus.  The  diagnosis  then  depends  upon 
the  presence  of  an  open,  relaxed  anus.  Relaxation  of  the  sphincter 
and  incontinence  of  the  bowel  may  occur  also  independently  of 
laceration. 

Results. 

The  results  of  incomplete  laceration  vary  with  the  extent  of 
injury  and  direction  of  the  tear.  The  extent  to  which  laceration  is 
visible  to  the  eye  is  not  a  safe  criterion,  for,  as  already  explained, 

Figure  266. 


Downward  pressure  on  the  pelvic  floor  in  labor.  This  figure  shows  how  the  muscles  and 
fascia  of  the  pelvic  floor  may  be  injured.  CV,  constrictor  vagina  muscle.  TP,  transversus 
perinei  muscle.  Gm,  gluteus  maximus  muscle.  BC,  bulbocavernous  muscle.  IRF,  ischiorectal 
fascia.    Coc,  coccyx.     The  left  transversus  perinei  muscle  is  being  torn. 


the  chief  injury  may  be  in  the  deeper  structures,  and  recognized  not 
by  sight,  but  by  the  effects.  The  effects  may  not  be  ajjparent  immedi- 
ately after  labor  •  hence  further  examination  is  a  necessary  part  of  the 
efficient  management  of  the  puerperium.  One  examination  should 
be  made  immediately  after  labor,  to  recognize  and  at  once  repair  such 
injury  as  may  at  that  time  be  visible ;  another  six  weeks  later,  to 
recognize  and  repair  any  deeper  injuries  to  the  perineal  fascia  or 
muscles. 


LACERATIONS  OF  THE  PERINEUM. 


543 


Complete  laceration,  being  usually  in  the  median  line,  does  not 
tear  the  supports  of  the  pelvic  floor  so  much  as  the  incomplete. 
Moreover,  if  the  direction  of  the  tear,  whether  complete  or  incom- 
plete, be  in  the  median  line,  the  muscles,  fasciae,  and  ligaments  are  not 
so  seriously  injured  as  they  would  be  if  the  tear  extended  trans- 
versely across  the  perineum,  especially  if  the  structures  were  torn 
from  their  pubic  attachments. 

Figure  266  shows  the  child's  head  pressing  strongly  downward 
upon  the  transversus  perinei  and  the  bulbocavernous  muscles  and 
the  rectovesical  fascia ;  such  pressure  gives  rise  to  great  sagging  of 


FiGUKE  267. 


Fresh  incomplete  tear  of  the  perineum.  Observe  the  rent  extending  outward  in  the  median 
line  toward  the  anus  and  inward  in  the  vaginal  sulci.  XX,  the  lowest  remains  of  the  hj-men 
on  each  side — carunculae  myrtiformes. 

the  pelvic  floor,  and  if  th*^  rectovesical  and  other  fasciae  are  injured 
extensively,  the  sagging,  unless  relieved  by  a  suitable  perineorrhaphy, 
is  apt  to  be  permanent.  After  the  injury  the  whole  pelvic  floor,  in- 
cluding the  rectum,  vagina,  urethra,  and  bladder,  now  deprived  of 
their  support,  tend  to  downward  and  backward  displacement  toward 
the  tip  of  the  coccyx.  The  rectum,  bladder,  and  vagina  fall,  as  the 
lower  jaw  would  fall  if  the  masseter  and  temporal  muscles  were  cut, 
or  as  a  tent  would  fall  if  the  guy  ropes  were  cut.  The  backward  dis- 
placement of  the  perineum  is  an  incident  and  an  index  of  the  sagging. 
In  very  many  of  the  worst  cases  the  injury  is  mainly  intra  vaginal, 


544 


TRAUMATISMS. 


and  shows  little  or  no  external  evidence  of  laceration — that  is,  the 
cutaneous  structures  between  the  anus  and  the  posterior  commissure 
of  the  vulva  may  be  unbroken.  The  palpable  and  visible  split  in  the 
perineum  may  have  relatively  little  significance;  but  injury  to  the 
rectovesical  fascia  and  to  the  other  fasciae  of  the  pelvic  floor  may 
give  rise  to  displacement  of  the  pelvic  organs.  Injury  to  the  muscu- 
lar part  of  the  perineum  accounts  for  frequent  impairment  of  function 

F^GUKE  268. 


Fresh  complete  tear  of  the  perineum.  The  direction  of  rent  is  in  the  median  line.  The 
rectovaginal  wall  is  torn  apart  for  a  distance  of  about  one  inch.  XX,  lowest  carunculae  myrti- 
formes.    MM,  broken  ends  of  the  sphincter  ani  muscle. 


in  the  organs  whose  outlets  the  muscles  control — that  is,  in  the  blad- 
der, urethra,  vagina,  and  rectum. 

Rectocele. — Figure  264  shows  the  direction  of  the  anus  to  be  at  an 
angle  to  that  of  the  rectum,  so  that  as  fecal  matter  comes  dowai  it 
must,  in  passing  from  the  rectum  out  through  the  anus,  turn  this 
angle ;  in  so  doing  it  strikes  against  the  rectal  side  of  the  perineum, 
and  thence  is  deflected  through  the  anus.  If  the  injury  to  the  peri- 
neal body  has  made  it  thin,  weak,  or  relaxed,  or  otherwise  impaired  its 


LACERATIONS  OF  THE  PERINEUM. 


545 


resisting  power,  the  downward  force  of  the  feces,  instead  of  being 
deflected  backward  and  outward,  will  cause  the  posterior  vaginal  wall 
to  pouch  forward  into  the  vagina.  This  pouch  is  a  rectocele.  The 
fecal  matter  thus  arrested  requires,  with  the  enlarging  pouch,  more 
and  more  force  for  its  expulsion,  and  the  pouch  therefore  will  in- 
crease ;  the  result  will  be  rectal  and  anal  tenesmus,  irritation,  and 
sometimes  anal  fissure  or  fistula,  or  hemorrhoids. 

Figure  269. 


Same  as  Figure  268.  The  torn  parts  are  being  held  together  with  the  fingers,  so  that  X  coin- 
cides with  X  and  M  with  M.  This  adjustment  shows  what  parts  should  be  united  iu  repair  of 
the  injury. 

Cystocele. — The  perineum  having  been  impaired  by  rupture,  the 
vesicovaginal  septum,  which  normally  rests  upon  it,  tends  to  sag  and 
bulge  forward  into  the  vaginal  outlet  in  the  form  of  a  pouch.  This 
pouch  is  called  cystocele.  The  patient,  except  in  the  knee-chest  posi- 
tion, may  not  be  able  to  empty  the  bladder  completely.  Residual 
urine  may  accumulate  in  the  pouch,  decompose,  irritate  the  bladder, 
and  may  set  up  cystitis  or  may  lead  to  the  formation  of  stone  in 
the  bladder.  In  order  to  expel  the  contents  of  the  bowel  the  woman 
may  have  to  hold  back  the  protruding  organs  with  the  hand. 


546 


TRAUMATISMS. 
Figure  270. 


Relaxation  of  the  vaginal  outlet  consequent  upon  labor.    The  injury  is  confined  entirely  to  the 
interior,  no  cutaneous  rent.    'Ihe  perineum  is  extremely  thin. 

Figure  271. 


Same  as  Figure  270.    The  index-finger  in  the  rectum  forces  the  rectocele  forward  through  tho 

vulva. 


LACERATIONS  OF  THE  PERINEUM. 

Figure  272. 


547 


Cystocele  and  rectocele  consequent  on  injury  to  the  vaginal  outlet. 

The  downward  force  of  straining  at  stool  to  empty  the  bladder  and 
rectum   increases   the   prolapse    of    the  vaginal    wall,    which,    being 

Figure  273. 


Same  as  Figure  272.    Cystocele  and  rectocele  shown  in  section.    The  protruding  vaginal  wall 
drags  the  uterus  down  after  it. 


64S  TRAUMATISMS. 

attached  to  the  uterus,  drags  that  viscus,  together  with  its  appendages 
and  the  rest  of  the  pelvic  floor,  to  a  lower  level,  and  thereby  gives 
rise  by  traction  to  various  displacements  of  the  reproductive  organs. 

A  wide  range  of  organic  and  mechanical  disorders  naturally  result 
from  the  above  conditions ;  among  them  swelling  of  the  vaginal  walls, 
bearing-down  sensations,  a  feeling  that  the  "  bottom  has  dropped 
out,"  difficulty  of  walking  and  standing,  backache,  constipation,  and 
many  nervous  disturbances. 

The  relaxed  or  lacerated  introitus  vaginae  permits  air  to  accumu- 
late in  the  vagina,  and  at  intervals,  on  slight  change  of  position,  to 
be  expelled  suddenly  with  an  audible  sound  (garrulity  of  the  vulva), 
which  simulates  the  sound  made  by  the  passage  of  flatus  from  the 
bowel. 

Chronic  nervous  invalidism  is  the  possible  indirect  result  of  lacera- 
tion of  the  perineum.  This  subject  is  discussed  further  in  the  chap- 
ters on  displacements. 


CHAPTER    XLI. 

PERINEORRHAPHY. 

One  of  the  most  important  and  most  serious  maxims  in  gynecology 
should  be,  "  Never  attempt  the  primary  or  secondary  closure  of  a 
torn  perineum  until  you  have  fully  and  clearly  demonstrated  and 
appreciated  the  direction  or  directions  and  extent  of  the  injury."  ^ 
Perineorrhaphy  in  a  properly  broad  sense  comprises  not  merely  the 
closure  of  the  torn  perineum,  but  as  well  the  repair  of  the  injuries, 
both  deep  and  superficial,  of  other  structures  in  the  perineal  region. 

DIRECTION  OF  THE  TEAR. 

A  number  of  years  ago  the  writer  was  called  to  make  immediate 
repair  of  an  incomplete  though  extensive  rupture  of  the  perineum. 
He  had  the  belief,  then  commonly  held,  that  such  a  rupture  was 
usually  a  splitting  apart  of  the  perineal  body  into  two  lateral  frag- 
ments which  at  once  retracted  to  the  corresponding  sides.  Accord- 
ingly, sutures  were  introduced  from  side  to  side  in  a  way  to  reunite 
the  lateral  fragments  by  a  line  of  union  which  should  extend  in  the 
median  line  from  the  cutaneous  to  the  vaginal  side  of  the  perineal 
body.  The  amazing  result  of  this  procedure  was  almost  complete 
closure  of  the  vulva  so  that  the  index-finger  could  only  with  difficulty 
be  introduced  into  the  vagina. 

The  absurdity  of  the  situation  was  more  apparent  than  the  explana- 
tion ;  evidently  the  lacerated  surfaces  had  not  been  brought  together 
properly — but  why  ?  Upon  removal  of  the  sutures  the  torn  surfaces 
were  exposed  again.  A  study  of  the  injury  then  was  made  by  hook- 
ing together  opposite  sides  of  the  torn  surfaces  in  different  directions 
with  tenacula.  The  result  of  the  experimental  approximations  finally 
demonstrated  the  direction  and  character  of  the  rent. 

The  four  diagrams  under  Group  I.,  Figure  274,  explain  the  nature 
of  this  lesion  and  the  operation  of  repair.  Diagram  1  shows  the 
margins  of  the  wound  before  approximation.  Diagram  2  shows  the 
approximation,  the  correctness  of  which  was  demonstrated  by  the  fact 
that  all  the  little  irregularities  accurately  fitted  into  one  another,  and 
that  the  integrity  of  the  vaginal  outlet  Avas  restored.  Diagram  3 
shows  the  sutures  in  position,  but  not  tied.  Diagram  4  shows  the 
lines  of  union  and  the  sutures  tied.  The  line  abc,  Diagram  4, 
represents  the  line  of  tear  extending  from  side  to  side  across  the 
vaginal  outlet  inside  the  vulva ;  the  point  6  is  situated  in  the  median 
line ;  points  a  and  c  represent  the  extremities  of  the  vaginal  portion 
of  the  rupture,  which  extended  high  up  across  the  lateral  walls  of  the 

1  E.  C.  Dudley.  Chicago  Clinical  Review,  April,  1894.  The  accompanying  description  of 
perineorrhaphy  is  adapted  from  this  paper. 

549 


550 


TRAUMATISMS. 

Figure  274. 


GROUP  I. 


GROUP  II. 


Diagram  1. 


Diagram  1. 


Diagram  2. 


Diagram  2. 


Diagram  3. 


Diagram  3. 


^ 


die 


X 


Diagram  4. 


X 


Diagram  4. 


PERINEORRHAPHY. 
Figure  275. 


551 


GROUP  in. 


GROUP  IV. 


Diagram  1. 


Diagram  1. 


Diasram  2. 


Diagram  3. 


Diagram  2. 


Diagram  3. 


Diagram  4. 


Diagram  4. 


552  .        TRAUMATISMS. 

vaginal  outlet  in  a  direction  parallel  to  the  sides  of  the  vulva.  The 
arrow-heads  show  the  directions  in  which  the  fragments  retracted 
after  the  rupture  until  the  exposed  surfaces  assumed  the  shape  shown 
in  Diagram  1. 

The  explanation  of  the  closure  of  tlxe  vulva  by  the  first  procedure 
is  now  clear.  It  was  the  result  of  a  line  of  union  made  at  right 
angles  to  the  actual  line  of  tear — that  is,  the  vaginal  portion  of  the 
rupture  had  been  from  side  to  side,  or  in  the  transverse  direction  ;  it 
was  closed  as  if  it  had  been  a  longitudinal  instead  of  a  transverse 
tear.  This  would  necessarily  close  the  vulva  to  a  point  as  high  as 
the  injury  extended  on  either  side.^ 

In  order  to  explain  clearly  the  mechanism  of  the  rupture  shown 
in  Group  I.,  attention  is  called  to  another  and  ve7"i/  rare  form  of  rupt- 
ure, known  as  complete  central  ruj)ture  of  the  perineum — that  is,  a 
rupture  in  which  the  child  is  produced  not  through  the  vulva,  but 
through  a  perforation  extending  from  the  vaginal  side  of  the  perineal 
body,  directly  through  the  perineal  body  to  its  cutaneous  side,  where 
the  birth  is  completed  between  the  vulva  and  the  anus.  This  com- 
plete, central  rupture  of  the  perineum  takes  place  in  the  transverse, 
not  in  the  longitudinal  direction.  The  transverse  direction  is  deter- 
mined by  the  general  arrangement  of  the  muscles  and  fascia  surround- 
ing the  vulva,  the  fibres  of  which  run  for  the  most  part  in  that 
direction  and  therefore  are  separated  more  readily  in  a  longitudinal 
than  in  a  transverse  direction. 

The  vast  majority  of  lacerations  begin  as  complete  central  rupt- 
ure, following  the  direction  of  least  resistance — that  is,  transversely ; 
and  continue  until  considerable  progress  has  been  made  in  the  separa- 
tion of  the  perineal  structures  into  anterior  and  posterior  fragments 
(line  abc,  Group  I.,  Diagram  4).  Then,  instead  of  continuing  to 
complete  central  rupture  and  perforation  of  the  perineal  body, 
the  expulsive  forces  are  opposed  more  and  more  by  the  strength 
of  the  deeper  perineal  structures,  the  direction  of  least  resistance 
changes  to  the  longitudinal,  with  a  corresponding  change  in  the  direc- 
tion of  the  rupture,  which  now  takes  the  longitudinal  direction  shown 
in  line  6/,  Diagram  4.  Notice  the  direction  of  retraction  of  the 
three  torn  fragments  as  shown  by  the  arrow-heads  in  Diagram  4, 
a  retraction  which  makes  the  irregular,  torn  surface  of  Diagram  1. 
The  exposed  surface  of  Diagram  1,  being  partially  intravaginal,  often 
requires  for  its  demonstration  the  sides  of  the  vulva  to  be  separated, 
or  the  perineum  to  be  lifted  forward  by  the  index  and  middle  fingers 
in  the  rectum. 

The  diagrams  in  Group  I.  represent  a  typical  perineal  laceration  ; 

1  At  the  meeting  of  the  American  Medical  Association  in  June,  1883,  I  described  the  trans- 
Terse  laceration  of  the  perineum  and  its  operative  treatment.  The  paper  was  published  in  the 
Transactions  of  the  Association  of  that  year.  This  paper  had  reference  only  to  the  recent  lace- 
ration and  the  immediate  operation.  In  the  first  edition  of  Emmet's  Principles  and  Practice 
of  Gynsecology,  which  appeared  about  six  months  later,  that  author  gave  to  the  profession  the 
epoch-marking  operation  on  the  vaginal  outlet  which  has  since  been  known  by  his  name.  Em- 
met's observations  had  special  reference  to  the  secondary  operation,  and  were  made  without 
knowledge  of  my  studies  upon  the  recent  laceration,  as  mine  were  made  without  knowledge  of 
his  work  in  the  secondary  operation.  It  is  the  great  credit  of  Emmet  to  have  given  to  the  pro- 
fession a  secondary  operation  which  brings  the  posterior  vaginal  wall  up  against  the  anterior 
more  perfectly  than  any  other  ;  this  operation,  however,  though  of  wide,  is  not  of  universal, 
application.  Besides,  there  are  some  matters  of  technique,  soon  to  be  described,  which  add 
greatly  to  the  result  in  bringing  the  perineum  up  to  the  pubes. 


PERINEORRHAPHY.  553 

the  other  three  groups  of  Figures  274  and  275  show  various  modifi- 
cations of  this  type.  In  each  of  these  four  groups  Diagram  1  represents 
the  exposed,  torn  surface  of  the  bruised  and  distorted  vaginal  outlet, 
which  approximates  in  each  instance  a  polygon  or  an  approximate  circle 
bounded  by  a  broken  outline.  It  is  an  interesting  fact  that  the  de- 
scription of  any  one  of  these  torn  surfaces  will  without  change  apply 
perfectly  well  to  any  other — that  is,  when  the  labia  are  separated, 
the  outline  of  the  torn  surfaces  does  not  necessarily  give  a  definite 
idea  of  the  direction  of  the  rent.  For  example,  the  rent  may  be  in 
the  anteroposterior  direction,  and  the  two  lateral  fragments  may 
have  retracted  to  the  corresponding  sides,  making  the  outline  of 
the  laceration  as  shown  in  Group  IV.,  Diagram  1 ;  or  the  rent  may 
have  occurred  transversely,  and  the  torn  fragments  may  have  re- 
tracted, the  one  toward  the  vaginal  outlet  and  the  other  toward  the 
upper  end  of  the  vagina,  leaving  a  similar  torn  surface,  the  outlines 
of  which  are  shown  in  Group  III.,  Diagram  1.  This  indefiniteness 
in  shape  of  outlines  in  the  exposed  surfaces  in  the  four  groups  is  not 
only  consequent  upon  the  retraction  of  the  torn  fragments,  but  it  is 
also  caused  by  the  loose,  fllabby,  contused,  rasped  condition  of  the 
vaginal  outlet — a  condition  common  at  the  end  of  parturition. 

Notice  Diagram  4  in  each  of  the  four  groups.  In  Group  I.  the 
lines  of  the  tear  correspond  approximately  to  the  shape  of  the  letter 
Y.  The  upper  part  of  the  letter  describes  the  transverse,  vaginal 
portion  of  the  tear ;  the  staff  describes  the  longitudinal,  vulvo- 
vaginal portion.  We  really  have  three  distinct  lines  of  rupture:  one 
shown  by  the  line  ah,  another  by  the  line  he,  and  the  third  by  the  line  hj. 
Lines  he  and  6/ of  this  figure  describe  the  rupture  of  Group  II.  In 
Group  II.  the  vaginal  portion  of  the  rupture  runs  diagonally  to  the 
patient's  left.  A  precisely  similar  condition  would  be  that  in  which 
the  vaginal  portion  of  the  rupture  runs  diagonally  to  the  patient's 
right ;  so  that  we  may  have,  in  addition  to  Group  II.,  in  which  the 
laceration  is  left-lateral,  a  precisely  similar  injury  in  which  it  would 
be  right-lateral.  Lines  ah  and  he.  Group  I.,  describe  the  rupture  of 
Group  III.  ;  line  hf,  Group  I.,  describes  the  rupture  of  Group  IV. 

One  may  find,  therefore,  in  the  study  of  individual  cases,  by  ap- 
proximating the  margins  of  the  tear  with  tenacula,  that  the  injury 
may  correspond  to  any  one  or  all  of  the  lines  in  Group  L,  or  to  any 
combination  of  them.  It  may  further  show  any  variation  in  the 
length  or  regularity  of  these  lines.  It  is  a  cardinal  principle  that,  be 
these  lines  ever  so  variable  in  length  and  regularity,  they  can  always 
be  referred  to  the  typical  lines  shown  in  Diagram  4,  Group  I. 

The  letters  which  have  been  used  to  designate  the  different  points 
in  each  cut  have,  for  purposes  of  convenience,  been  made  to  corre- 
spond one  for  all.  For  example,  point  6  in  Diagram  3,  Group  III., 
occupies  the   same  relative  position  as  point  h  in  any  other  figure. 

It  is  important  to  appreciate  the  mechanism  of  the  injury  as  indi- 
cated by  the  arrow-heads  in  Diagram  4  of  each  group.  They  show 
the  direction  in  which  the  torn  fragments  retract  to  make  the  broken 
outline  indicated  by  Diagram  1  of  each  group. 

The  upper,  branching  portion  of  the  Y-shaped  tear  indicates  exten- 


554  TRAUMATISMS. 

sive  injury  to  the  perineal  muscles  and  fasciae,  especially  the  trans- 
versus  perinei  muscle,  and  requires  deep  denudation  and  deep  suture 
to  catch  the  impaired  structures. 

The  further  description  of  perineorrhaphy  for  incomplete  rupture 
will  be  shown  in  Figures  276  to  287.  In  these  Figures  the  letters  a, 
b,  c,  d,  e,  and  /  indicate  the  same  points  and  landmarks  which  they 
indicate  in  the  diagrams  of  Figures  274  and  275.  The  chief  points 
and  landmarks  have  been  pointed  out ;  they  are,  the  lowest  remains 
of  the  hymen  and  the  crest  of  the  rectocele ;  if  there  be  no  rectoceie, 
the  point  would  be  where  its  crest  would  be  if  there  were  one. 

PREPARATORY  TREATMENT  FOR  PERINEORRHAPHY. 

The  preparatory  treatment  consists  of  movements  of  the  bowels 
and  sterilization  of  the  field  of  operation,  as  described  in  Chapter  II. 

TECHNIQUE  OF  PERINEORRHAPHY  FOR  INCOMPLETE  RUPTURE. 

Primary  Operation. 

In  the  primary  operation — that  is,  the  operation  on  the  recently 
torn  surfaces,  denudation,  except  possibly  the  trimming  off  of  any 
ragged  edges  of  the  wound,  is  unnecessary.  In  other  respects  the 
operation  is  substantially  the  same  as  the  secondary  operation. 

Secondary  Operation. 

When  the  torn  surfaces  have  healed  over  and  cicatrized,  after  an 
unsuccessful  primary  operation  or  after  no  operation  at  all,  correct 
denudation  is  essential,  and  is  made  possible  only  by  studying  the 
lines  of  the  original  tear  by  means  of  a  tenaculum  in  each  hand  and 
having  in  mind  the  remains  of  the  hymen  and  the  crest  of  the  recto- 
cele as  follows  : 

When  labor  has  not  resulted  in  laceration,  the  vaginal  outlet  will 
be  surrounded  by  the  remains  of  the  hymen,  which  mark  off  the 
vulva  from  the  vagina — that  is,  by  the  carunculge  myrtiformes. 
These  consist  of  numerous  small  protuberances  situated  near  together 
and  surrounding  the  vulva,  as  it  were,  like  a  string  of  beads.  They 
are  sometimes  so  close  together  and  pronounced  as  almost  to  constitute 
an  annular  hymen. 

This  circular  line  of  carunculse  myrtiformes,  in  case  of  laceration, 
is  broken  at  a  point  near  the  posterior  commissure  of  the  vulva,  and 
when  the  break  occurs  the  lowest  caruncle  on  either  side  of  the 
rirpture  is  retracted  to  the  corresponding  side  of  the  vulvar  outlet. 
In^  a  typical  laceration,  the  two  lowest  caruncles  will  correspond  to 
points  d  and  e^  in  the  diagrams  of  Group  I.,  Figures  274  and  275. 
Their  location  is  indicated  also  in  the  corresponding  points  of  Groups 
II.  and  ly.  Figures  276  to  291  show  the  caruncles  as  they  appear 
in  the  various  stages  of  the  operation.  Group  III.,  being  a  transverse 
laceration,  does  not  involve  the  caruncles.     The  two  lowest  caruncles, 


PERINEORRHAPHY,  555 

on  being  approximated  by  the  tenacula,  show  the  surfaces  to  be  united 
iu  the  external  parts  of  the  rupture. 

Having  located  the  two  lowest  caruncles  find  some  point  near  the 
centre  of  the  upper  fragment,  point  b,  Figure  276  (if  a  rectocele 
has  formed,  this  'will  be  its  crest),  and  while  the  two  caruncles  d  and 
e  are  being  held  together,  let  point  b  be  drawn  into  coincidence  with 
points  d  and  e.  Then  will  the  points  6,  d,  and  e  come  together  and 
form  one  and  the  same  point.  The  coincidence  of  these  three  points 
will  show  what  surfaces  should  be  denuded  and  united  upon  them- 
selves. 

Remove  the  tenaculum  at  d,  and  reintroduce  it  at  /.  Then 
consider  tenacula  b,  e,  and  /  as  hooking  np  the  three  angles  of  a 
plane  triangle.  Let  traction  on  the  angles  of  this  triangle  be  made 
by  these  tenacula  in  the  hands  of  assistants,  the  direction  of  the 
traction  being  from  the  centre  of  the  triangle  toward  each  angle. 
The  surfaces  now  put  upon  the  stretch  should  be  denuded.  This  com- 
pletes the  denudation  on  the  left  side.  Figures  278  and  279.  Then 
remove  the  tenaculum  at  point  e,  reintroduce  it  at  point  c/,  place  the 
included  triangle  bdf  upon  the  stretch,  and  denude  as  before.  This 
completes  the  denudation  on  the  right  side. 

Then  remove  the  tenaculum  at  point  /  and  reintroduce  it  at  point 
c,  making  upward  traction,  and  at  the  same  time  approximating 
points  6  and  e  wdth  other  tenacula. 

Then  the  surface  bee,  Figure  280,  is  to  be  united  upon  itself 
with  a  line  of  sutures  so  as  to  bring  the  line  be  in  coincidence  with 
the  line  ce.  In  like  manner  line  ba  must  be  brought  into  coinci- 
dence with  line  ad.  Finally,  other  sutures  close  the  external  rent, 
def,  upon  itself.  Observe  the  suture  of  which  the  entrance  and  exit 
are  at  points  e  and  d,  and  which  catches  up  point  h,  Figures  280  to 
283.  This  suture,  which  is  the  "  crown  stitch  "  of  Eiuniet,  brings 
points  6,  d,  and  e  into  coincidence.  (See  Diagram  4.  Groups  I.  and 
ly.  ;  in  Figures  274  and  275.) 

In  the  introduction  of  sutures  one  of  the  greatest  principles  of 
plastic  surgery  should  be  observed,  namely,  that  freedom  from  wound- 
disease  and  consequent  union  require  the  sutures  from  their  points  of 
entrance  to  their  points  of  exit,  so  far  as  practicable  to  be  buried,  so 
that  they  shall  not  anywhere  appear  in  the  exposed  surfaces. 

Each  suture  should  be  tied  before  introducing  the  next,  instead  of 
first  introducing  all  the  sutures  and  tying  them  afterward,  as  is 
done  usually.  One  reason  for  this  is  that,  under  the  former  method, 
the  sutures  are  less  likely  to  antagonize  one  another. 

In  a  typical  laceration  after  the  crown  suture  has  been  introduced 
(Figure  280)  let  the  next  suture  be  introduced  and  tied  in  the  angle 
or  sulcus  on  one  side,  point  c.  The  free  ends  should  not  be  cut 
immediately,  but  left  long  and  given  into  the  hand  of  an  assistant,  who 
should  make  firm  traction  upon  them  in  the  upward  direction  toward 
the  pubes  while  the  next  suture  is  being  placed  and  tied,  when  the 
long  ends  of  this  suture  are  also  given,  with  the  preceding  one,  into 
the  hand  of  the  same  assistant.  Then  introduce  the  third  suture, 
while  firm  traction  is  being  made  on  the  first  two,  precisely  as  the 


556  TEA  VMATISMS. 

second  was  introduced,  and  so  on  until  the  required  number  has 
been  inserted  on  that  side.  Repeat  this  on  the  opposite  side ;  or  the 
sutures  may  be  introduced  as  shown  in  Figures  280  and  281,  one  in 
one  sulcus  and  one  in  the  other,  and  so  on  until  both  sulci  are  closed. 

Then  introduce  a  suture  under  the  lowest  caruncle  on  the  left  side, 
through  the  crest  of  the  rectocele,  or  the  centre  of  the  upper  fragment, 
carrying  the  suture  around,  buried  all  the  way,  out  through  the  lowest 
caruncle  on  the  oijposite  side.  This  is  parallel  to  and  supplements  the 
crown  suture  already  mentioned,  and  aids  it  in  holding  the  three  points, 
6,  d,  and  e,  together.  With  the  tying  of  this  and  the  crown  suture 
the  vaginal  portion  of  the  operation  is  complete.  Figures  282  and 
283.  The  buried  suture  mentioned  above  is  not  shown  in  the  illus- 
trations. 

The  external  or  vulvar  portion  is  closed  in  the  same  way — that  is, 
while  each  suture  is  being  introduced  and  tied,  firm  traction  is  made 
upward,  in  the  direction  of  the  pubes,  on  the  preceding  sutures. 

If  the  perineum  be  closed  in  this  way,  it  is  surprising  to  see  how  it 
will  be  brought  up  so  as  fairly  to  hug  the  tubes.  Indeed,  the  poste- 
rior part  of  the  vaginal  outlet  will  almost  exert  pressure  upon  the  pubes 
and  neck  of  the  bladder.  By  this  method  the  operator  should  never 
fail  to  get  the  perineum  into  its  normal  position  and  location. 

Material  for  Sutures. — Silkworm  gut  is  preferred.  The  free  ends 
of  the  sutures  are  left  long.  Numerous  devices  have  been  used  by 
many  operators  so  to  dispose  of  these  ends  as  to  prevent  them  from 
irritating  the  patient.  Emmet  ties  them  in  a  fan-shaped  bundle  and 
leaves  them  between  the  thighs ;  others  cut  them  short.  The  irrita- 
tion and  suiFering  from  this  source  are  so  extreme  that  some  operators 
have  used  sutures  of  softer  material,  such  as  silk  or  catgut ;  but  such 
material  is  objectionable  because  the  sutures  absorb  the  wound-secre- 
tions, which  secretions  may  decompose  and  produce  suppuration. 

I  have  for  several  years  used  a  device  which  entirely  obviates  this 
difficulty.  All  tlie  sutures  are  left  long  enough  so  that  they  may  be 
laid  down  upon  the  vaginal  surface  and  directed  toward  the  upper  end 
of  the  vagina.  The  sutures  are  well  turned  into  the  vagina  and  held 
there  by  an  additional  or  binding  stitch  which  is  tied  over  them  and 
is  situated  just  beyond  the  crown  stitch.  The  free  ends  of  this  binding 
stitch  are  bent  inward  also  in  the  direction  of  the  long  axis  of  the 
vagina.     See  Figures  284,  285,  286,  and  287. 

A  study  of  Groups  II.,  III.,  and  IV.,  Figures  275  and  276,  will 
furnish  a  guide  to  the  operation  in  atypical  cases. 

After-treatment. — The  patient  is  not  catheterized  unless  unable 
to  pass  urine.  Urine  in  contact  with  the  wound  is  harmless,  the  cath- 
eter, even  though  used  antiseptically,  is  apt  to  set  up  cystitis.  She  is 
permitted  to  lie  in  any  position.  The  conventional  roll  under  the 
knees  and  bandaging  of  the  thighs  are  unnecessary  except  for  the 
comfort  of  the  patient. 

The  external  sutures  should  be  removed  in  twelve  to  fourteen  days 
(Figure  286);  the  vaginal  sutures  in  about  twenty  days.  The  removal 
of  the  latter  is  facilitated  by  the  use  of  Sims'  speculum  reversed — 
that  is,  hooked  under  the  pubes,  the  patient  being  on  the  back.    (Figure 


PERINEORRHAPHY.  557 

Figure  276.  Figure  277. 


Figure  276. — Typical  incomplete  laceration  of  the  perineum.  The  tenaculum  hooked  into 
the  crest  of  the  rectocele  at  point  b  draws  it  slightly  forward.  The  other  two  tenacula  are 
hooked  into  the  lowest  remains  of  the  hymen,  points  d  and  e  (caruncula;  myrtiformesj.  The 
three  tenacula  if  approximated  would  bring  into  coincidence  points  b,  d,  and  e,  and  would 
show  what  surfaces  should  be  united. 

Figure  277. — Same  as  276.  Tenaculum  at  d  removed  and  placed  at  f.  Tenacula  b,  e,  and  f 
make  traction  so  as  to  render  tense,  lift  up  and  expose  for  denudation  the  torn  sulcus  of  the 
left  side.  The  ridges  formed  by  the  structures  drawn  taught  indicate  the  outline  of  the  surface 
to  be  denuded. 


Figure  278. 


Figure  279. 


Figure  278.— Denudation,  with  Emmet's  slightly  curved  scissors,  of  the  surface  exposed  in 
Figure  277.  A  strip  is  denuded  all  around  the  surface,  leaving  an  undenuded  island  in  the 
centre,  which  retracts  to  small  size. 

Figure  279. — The  island  of  undenuded  surface  left  after  denudation  of  the  strip  around  the 
surface,  exposed  in  Figures  277  and  288,  is  being  hooked  up  by  a  tenaculum  and  removed  with 
scissors. 

287.)     During  convalescence  the  patient  may  lie  in  any  desired  posi- 
tion.    When  the  patient  is  on  the  back  the  legs  and  thighs  may  be 

34 


558 


TRAUMATISMS. 


Figure  280. 


Figure  281. 


T'lGDRE  280.— The  denudation  shown  on  the  left  side  of  the  vaginal  outlet  in  Figures  278  and 
279  has  been  carried  out  on  both  sides  in  this  Figure.  A  suture,  called  the  crown  suture,  has 
been  passed  under  the  left  caruncle  e,  through  the  crest  of  the  rectocele  b,  and  under  the  right 
caruncle  d.  This  suture,  when  tied  later,  will  bring  these  three  points  together  ;  before  being 
tied  it  serves  as  a  guide  to  the  surfaces  to  be  united  in  the  two  sulci.  Two  sutures  introduced 
and  tied  in  each  sulcus  at  the  two  lateral  angles  of  the  laceration  are  held  taught  by  an  assist- 
ant ;  a  third  suture  is  being  introduced  on  the  left  side. 

Figure  281.— Five  sutures  have  been  introduced  and  tied  in  the  right  sulcus  and  four  in  the 
left.  While  the  nurse  is  making  strong  traction  upward  on  these  sutures,  the  final  suture  of 
the  left  sulcus  is  being  passed. 


Figure  282. 


Figure  283. 


Figure  282.— All  the  sutures  in  the  two  sulci  have  been  introduced  and  tied.  While  the 
nurse  is  making  strong  traction  upward,  the  crown  suture  (shown  in  Figures  280  and  281),  which 
brings  together  the  two  caruncles  and  the  crest  of  the  rectocele,  is  being  tied.  This  completes 
the  intravaginal  part  of  the  operation. 

Figure  283.— The  sutures  which  have  completed  the  intravaginal  part  of  the  operation  are 
being  drawn  strongly  upward  by  the  nurse,  so  as  to  lift  the  perineum  toward  the  pubes  while 
the  first  suture  of  the  external  part  of  the  operation  is  being  passed.  Observe  the  action  of  the 
finger  in  making  counterpressure  as  the  needle  is  passed  through.  Notice  also  that  the  needle 
is  shown  at  the  bottom  of  the  wound.  The  general  rule  in  plastic  surgery  to  bury  the  suture 
completely  under  the  wound,  although  favorable  to  union,  is  disregarded  in  the  passage  of  these 
outside  sutures,  for  if  so  buried  they  would  include  and  draw  forward  into  the  restored  perineal 
body  the  rectocele.  The  rectocele,  however,  is  properly  a  portion  of  the  rectovaginal  wall,  and 
in  order  tliat  it  may  take  its  normal  place  back  of  the  restored  perineum  it  should  not  be  in- 
cluded in  these  sutures  ;  in  fact,  during  the  passage  of  the  external  sutures  it  should  be  forced 
back  to  the  depth  of  the  wound  by  means  of  the  finaer  introduced  into  the  wound  so  as  to  per- 
mit the  denuded  surfaces  to  be  brought  together  in  front  of  it. 


PERINEORRHAPHY.  559 

Figure  284.  Figurk  'JSo. 


Figure  284.— The  sutures  intended  for  closure  of  the  perineum  having  all  been  tied  are  now 
temporarily  held  down  and  away  from  the  vulva,  as  shown  in  this  Figure.  This  is  to  facilitate 
the  passage  of  a  special  suture  just  back  of  the  crown  suture.  As  soon  as  this  special  suture  has 
been  passed,  and  before  it  is  tied,  the  bundle  of  sutures  is  returned  to  its  former  position,  as 
shown  in  the  next  Figure.  The  purpose  of  the  suture  now  being  passed  will  become  apparent 
in  the  next  two  Figures. 

Figure  285.— The  special  suture  introduced  in  the  last  Figure  is  now  being  tied :  its  purpose 
is  to  secure  in  a  bundle  the  other  sutures  and  hold  them  down  against  the  posterior  wall  of  the 
introitus  vaginae.  The  next  Figure  will  show  all  the  sutures  turned  into  the  vagina.  The  special 
suture  retains  them  there.  The  free  ends  of  this  retention-suture  are  carried  with  the  others 
into  the  vagina. 


Figure  286. 


Figure  287. 


Figure  286. — This  sectional  view  of  the  sutures  in  position  and  tied  completes  the  illus- 
trations of  the  secondary  operation  for  incomplete  laceration  of  the  perineum.  The  entire 
bundle  of  sutures  is  shown  turned  into  the  vagina,  where  they  canncjt  irritate  the  wound.  This 
arrangement  permits  adequate  dressings  over  the  external  part  of  the  wound,  and  does  away 
with  the  irritating  and  distressing  ends  of  the  sutures  which  commonly  are  left  in  contact  with 
the  external  surfaces,  and  which  always  contribute  enormously  to  the  discomfort  and  pain  of 
convalescence.  A  section  of  a  Sims  specxilum  is  shown  here.  The  instrument  introduced  in 
this  way— z.  e.,  hooked  under  the  pubes,  with  the  patient  in  the  dorsal  positiim— facilitates  the 
turning  in  of  the  siuures  at  the  close  of  the  operation,  and  may  be  used  again  in  their  removal. 

Figure  287. — In  the  removal  of  a  suture  a  single  free  end  is  caught  with  the  forceps  and  the 
loop  cut  with  the  scissors  at  one  side  of  tlie  knot.  The  external  sutures  should  be  removed  at 
the  end  of  two  weeks,  and  the  intravaginal  sutures  at  the  end  of  three  weeks  The  vagina  is 
exposed  here  by  Sims' speculum  hooked  under  the  pubes  and  the  crown  suture  is  being  re- 
moved. The  remaining  sutures  are  drawn  out  of  the  vagina  and  removed  one  by  one.  Observe 
the  tenaculum  point  on  the  fine  blade  of  the  scissors,  which  holds  up  the  loop  and  guards 
againstthecuttingolf  of  the  knot  which  might  cause  the  loop  to  retract  out  of  reach.  A  pledget 
of  cotton  saturated  with  a  fi  per  cent,  solution  of  cocaine  retained  in  the  outlet  of  the  vagina 
for  ten  minutes  renders  removal  of  the  sutures  painless. 


560  TRAUMATISMS. 

more  comfortable  if  supported  on  a  roll  made  of  a  blanket,  comforter, 
or  pillow.  A  sterilized  douche  should  be  given  every  twelve  hours, 
and  the  external  parts  showered  off  after  urination  or  defecation. 
The  wound  is  dressed  antiseptically  with  a  pad  of  gauze  and  cotton 
held  in  place  over  the  vulva  by  a  T-bandage. 

If  secondary  hemorrhage  occur,  the  indication  is  for  anaesthesia 
and  prompt  ligature  of  the  bleeding  point.  For  this  purpose,  the 
parts  may  be  exposed  by  a  speculum.     Figure  267. 

Other  Operations  of  Perineorrhaphy. 

The  literature  of  the  subject  has  been  obscured  by  a  countless 
variety  of  operations  for  the  repair  of  the  perineum.  Every  medical 
student  is  appalled  by  their  number,  their  diversity,  and  their  com- 
plexity. It  is  hardly  possible,  however,  that  perineorrhaphy  should 
furnish  an  exception  to  the  great  general  principle,  that  progress  in 
any  direction  is  characterized  always  by  simplicity. 

The  object  of  perineorrhaphy  is  to  replace  rather  than  to  enlarge 
the  perineum.  Many  of  the  popular  stereotyped  operations  which 
enlarge  it  really  exaggerate  the  displacement. 

The  surgeon  often  is  asked  what  operation  he  performs  on  the 
perineum.  This  implies  that  there  is  some  fixed  operation  which  is 
universally  applicable.  It  would  be  no  less  absurd  to  ask  what 
plastic  operation  is  universally  applicable  to  lacerated  wounds  of  the 
face.  It  is  not  enough  for  an  operator  merely  to  get  union  at  any 
cost,  even  though  that  union  result  in  placing  a  solid  mass  of  flesh 
where  the  perineum  ought  to  be.  Great  harm  comes  if  the  parts 
brought  into  apposition  are  not  parts  which  belong  together. 

Most  of  the  stereotyped  operations  are  prized  because  they  make 
the  "  large,  solid,  perineal  body,"  but  such  a  perineum,  composed  of 
the  union  of  parts  which  do  not  belong  together,  may  be  unfit  for  the 
performance  of  its  functions,  and  may  be  very  prone  to  subsequent 
rupture. 

We  hear  much  said  about  various  stereotyped  operations,  the  aim 
of  which  is  to  make  a  "large,  solid,  perineal  body,"  a  so-called 
"  improvement  on  nature."  This  involves  a  radical  and  dangerous 
misconception.  The  large  perineal  body  is  contrary  to  nature,  is 
unnecessary,  is  a  disadvantage.  The  question  is  not  of  size,  but  of 
location.  If  the  perineum,  be  it  ever  so  small,  is  Avell  up  under  the 
pubes,  its  location  at  that  point  indicates  that  the  muscles  and  fascia 
of  the  pelvic  floor  are  performing  their  function  of  supporting  the 
pelvic  organs.  Let  us  have  an  end  of  the  fallacy  that  the  perineum 
supports  the  organs  because  it  is  large,  or,  for  that  matter,  in  a  certain 
sense,  that  it  supports  them  at  all.  By  its  location  and  integrity  it 
only  contributes  to  their  support  as  an  essential  part  of  the  pelvic 
floor.  In  its  normal  location  and  integrity  it  indicates  that  the  pelvic 
floor  is  giving  support  to  the  pelvic  organs,  is  doing  its  part  in  the 
prevention  of  prolapse,  is  fulfilling  its  functions.  A  torn  perineum 
properly  situated  may  be  adequate.  An  enormous  perineum,  if  dis- 
placed toward  the  coccyx,  or  relaxed,  may  require  operative  treatment. 


PERINEORRHAPHY.  561 

When  a  thoroughly  scientific  and  satisfactory  treatise  is  written  on 
the  subject  of  perineorrhaphy,  it  will  not  be  an  article  describing  the 
numerous  and  complicated  operations.  It  will  treat,  in  a  general  way, 
of  operating  in  such  a  manner  as  to  restore  the  parts  to  the  condition 
in  which  they  were  before  they  were  torn.  The  first  step  must  Ije  to 
find  the  landmarks,  and  Emmet  has  told  us  how  to  do  this  by  bring- 
ing together  the  lowest  carunculse  myrtiformes  on  either  side  with 
tenacula ;  when  this  has  been  done,  one  may  discern  the  directions  of 
the  original  rent  and  the  cicatrices.  On  the  correct  observation  of 
these  landmarks  will  depend  the  method  by  which  we  must  proceed 
to  restore  the  perineal  body  so  as  to  leave  the  vaginal  outlet  with  an 
annular  arrangement  of  the  remains  of  the  hymen.  Failure  to  study 
these  cases  with  the  remains  of  the  hymen  as  a  guide  accounts  for  the 
numerous  and  divergent  methods  of  perineorrhaphy. 

The  greatest  lesson  in  jperineorrhaphy  is  to  apply  the  elementary 
principle  that,  in  the  repair  of  a  wound,  the  essential  purpose  is  to 
restore  the  wounded  part  to  its  original  state.  Always  individualize 
each  case,  find  out  the  lines  of  tear,  their  direction,  their  length,  and 
then  put  the  fragments  back  where  they  were  before.  He  who  does 
this  will  do  a  different  operation  in  every  case,  but  he  will  do  one 
man's  operation — the  man  will  be  himself.  If  one  of  the  stereotyped 
operations  in  an  individual  produces  a  perfect  result,  it  will  be  not 
because  it  has  anything  like  universal  adaptation  to  the  repair  of  an 
injured  perineum,  but  because  it  chanced  to  fit  that  case. 

The  flap-splitting  opej-ation,  for  example,  usually  results  in  the  union 
of  parts  which  were  not  together  before  the  rupture,  and  perchance 
cannot  be  united  without  detriment  to  the  patient ;  it  is  often  per- 
formed with  little  judgment,  and  since  it  is  so  easy  that  a  tyro  can  do 
it,  has  become  popular.  The  principle  of  flap-splitting,  however,  as 
applied  to  perineorrhaphy,  has  great  value  in  so  far  as  it  may  enable 
the  operator  in  some  cases,  to  readjust  the  fragments  to  their  original 
relations.  If  used  with  skill  and  judgment,  in  some  cases  of  deep 
injury  to  the  fascia  it  serves  a  most  useful  purpose.  Its  broad  appli- 
cation beyond  this  has  done  great  and  irreparable  harm. 

The  buried  suture  in  perineorrhaphy  would  be  beyond  criticism  if 
its  use  were  not  occasionally  followed  by  infection.  Numerous  opera- 
tions in  the  hands  of  careful  aseptic  surgeons  have  resulted  in  sup- 
puration, burrowing  of  pus,  formation  of  rectovaginal  and  rectoperi- 
neal  fistulse,  and  dangerous  sepsis.  The  advantages  of  the  buried  over 
the  ordinary  interrupted  suture  which  is  tied  on  the  surface  do  not 
outweigh  this  danger. 

In  cases  of  extreme  cystocele  and  rectocele  it  is  often  necessary, 
especially  in  women  who  have  passed  the  menopause,  to  combine  with 
closure  of  the  perineum  the  removal  of  a  portion  of  the  vaginal  plate 
of  the  vesicovaginal  and  rectovaginal  walls — an  elliptical  piece  from 
the  anterior  vaginal  wall,  and  a  triangular  piece,  with  the  apex  toward 
the  uterus,  from  the  posterior  vaginal  wall.  The  margins  of  the  vag- 
inal wounds  thus  made  should  be  united  from  side  to  side  by  inter- 
rupted sutures.     The  purse-string  suture  of  Stoltz  never  should  be 


562 


TRAUMATISMS. 


used  because  it  tends  to  shorten  the  vagina  and  thus  to  displace  the 
uterus.     See  Surgical  Treatment  of  Procidentia  (Prolapsus  Uteri). 


COMPLETE    PERINEORRHAPHY. 

Perineorrhaphy  involving  the  sphincter  ani  muscle  diflPers  in  some 
details  from  the  operation  just  described  ;  first,  in  the  preparatory 
treatment ;  second,  in  the  denudation ;  third,  in  the  passage  of  the 
sutures ;  fourth,  in  the  after-treatment. 


Figure  288. 


Figure  289. 


■^m'^^Kfh* 

i 

K 

1^ 

l[^H 

^  v^ 

^            M  -**? 

7  \    x"-i.»«ir- 

^ 

FA  U  LT  I- 
METHOD 
OF    SUTURE 


FiorRE  288. — An  unsuccessful  result  after  three  operations  of  c  implete  perineorrhaphy. 
Such  failures  are  due  commonly  to  the  fault  of  the  operator  in  not  bringing  together  the  torn 
ends  of  the  sphincter  ani  muscle.  Observe  the  radiating  folds  tjelow  the  anus.  After  a  suc- 
cessful operation  these  folds  should  radiate  in  all  directions.  After  an  unsuccessful  operation 
they  only  radiate  downward,  as  shown  in  the  Figure.  The  retracted  ends  of  the  torn  m.uscle  are 
shown  by  the  small  pits  marked  MM,  Figures  288  to  290.  The  lower  sutures  should  always  be 
passed  through  the  ends  of  the  muscle,  as  shown  in  Figure  290. 

Figure  289. — Faulty  method  of  passing  the  anal  sutures.  Interrupted  sutures  placed  in  this 
manner  and  tied  on  the  bowel  side  of  the  wound  are  open  to  the  following  objections  :  1.  They 
make  a  long  line  of  union  which  is  exposed  to  the  hostile  environment  of  the  bowel.  2.  The 
knots  and  free  ends  of  the  suture  in  the  bowel  may  take  up  septic  secretions  and  carry  them  by 
capillary  attraction  to  the  deeper  parts  of  the  wound,  and  in  this  way  cause  infection  and  fail- 
ure of  union.    3.  A  long  line  of  union  is  difficult  to  protect  against  infection. 

Preparatory  Treatment. 

The  chances  for  union  of  the  wound  are  increased  by  limiting 
the  amount  of  feces  which  may  pass  over  it  during  the  first  days  fol- 
lowing the  operation  ;  hence  the  bowels  should  be  as  nearly  empty 
and  aseptic  as  practicable.  With  this  object  they  should  be  treated  as 
in  the  preparation  for  major  operations,  C'hapters  Y.  and  VI. 

Denudation. 

Figure  289  shows  the  rent  extending  up  into  the  rectovaginal 
septum.  At  points  M  and  M  are  two  pits  or  depressions  caused  by 
retraction  of  the  ends  of  the  sphincter  ani  muscle.  The  principal 
object  of  the  operation  is  the  union  of  these  ends  and  the  conse- 
quent  restoration  of  sphincteric    function.     The    denudation,  there- 


PERINEORRHA  PHY. 


563 


fore,  must  include  the  pits  or  depressions.  They  may  be  seen, 
though  not  always  without  careful  search,  at  either  side  of  the  anus. 
The  denudation  starts  just  below  the  pit  on  the  patient's  left,  and  is 
carried  around  on  the  margin  of  the  torn  rectovaginal  septum  to 
include  the  opposite  pit. 

A  common  fault  in  denudation  is  not  to  include  these  torn  ends  of 
the  sphincter.  Observe  carefully  that  they  are  situated  well  down  on 
a  level  with  the  posterior  margin  of  the  anus.     Failure  to  carry  the 


Figure  290. 


Figure  291. 


ff^ 

i 

^"^ 

^»^ 

i 

IMp\ 

f^S 

V/^^^^^^:^.'^]  M 

corF}E,:t 

METHOD 

N           ''  ^  ' 

OF  SUTLIR 

:                                        j)    ji        H 

' 

Figure  290.— The  purse-striiitr  method  of  suture.  This  draws  the  wound  into  a  small  com- 
pass ;  it  leaves  no  part  of  a  suture  in  the  bowel  to  absorb  and  carry  septic  secretions ;  the  inner 
angle  of  the  anal  portion  of  the  wound  is  drawn  down  to  the  margin  of  the  anus,  where  it  is  less 
liable  to  infection  than  if  the  wound  were  longer  and  exposed  to  the  interior  of  the  bowel. 
Experience  has  shown  that  this  method  of  suture  is  immeasurably  more  successful  in  securing 
primary  union  than  tliat  shown  in  Figure  289. 

Figure  291.— Represents  repair  of  a  complete  perineal  laceration  extending  into  the  lat- 
eral sulci  of  the  vagina.  The  three  sutures  which  reunite  the  ends  of  the  sphincter  ani  muscle 
are  tied  and  held  to  one  side  bv  forceps.  Vaginal  sulci  closed  with  five  stitches  on  each 
side,  which  are  tied  and  held  up  by  the  assistant.  The  needle  is  being  introduced  for  the  pass- 
age of  the  crown  stitch  which  unites  the  lowest  caruncles.  There  is  usually  no  rectocele  in 
complete  laceration.  The  remaining  sutures  to  be  passed  will  close  the  external  part  of  the 
wound.  Observe  that  the  folds  about  the  restored  anus  radiate  in  all  directions  instead  of 
downward,  as  in  Figure  288.    This  is  a  reliable  indication  of  the  adequacy  of  the  anal  sutures. 

denudation  well  below  them  clearly  would  defeat  the  object  of  suture. 
The  remaining  denudation  then  is  done  as  for  an  incomplete  rupture. 

Introduction  of  Sutures. 

The  sutures  should  be  of  silkworm  gut.  The  first  two  or  three 
should  be  introduced  to  the  left  of  the  anus,  should  pass  somewhat 
deeply  under  the  left  pit,  as  shown  in  Figure  290,  should  sweep 
around  under  the  border  of  the  torn  septum,  and  pass  under  the 
opposite  pit  and  emerge  to  the  right  of  the  anus.  Figure  291  shows 
the  ends  of  the  sphincter  united  by  the  three  lower  sutures.  The 
problem  now  is  simplified  to  that  of  an  incomplete  operation,  and 
the  remaining  sutures  are  placed  as  already  described  for  closure  of 
an   incomplete    laceration.     The   sutures,  having  been    tied,  are   all 


564  TRAUMATISMS. 

turned  into  the  vagina,  as  shown  in   Figure  286,  and  the  vulva  is 
protected  by  an  aseptic  gauze  dressing. 

Complicated  Operations. 

In  some  cases  of  complete  laceration  of  the  perineum,  and  more 
rarely  in  incomplete  laceration,  so  much  tissue  has  been  lost  from 
sloughing  or  from  repeated  denudation  in  former  unsuccessful  attempts 
at  closure,  that  the  denuded  surfaces  cannot  be  approximated  by  su- 
tures. In  such  cases  recourse  may  be  had  to  the  device  shown  in  Plate 
XIII.,  Chapter  XXV.  The  author  published  this  method  in  Sur- 
gery, Gynecology,  and  Obstetrics,  June,  1 906.  It  gave  a  good  result 
in  one  case  after  seven  unsuccessful  attempts  at  closure  by  the  ordinary 
method. 

After-treatment. 

A  full  cathartic  of  castor  oil  or  compound  licorice  powder  should 
be  given  on  the  third  day,  and  repeated,  if  necessary,  to  secure  free 
catharsis.  Excessive  catharsis,  producing  frequently  repeated  liquid 
stools,  might  set  up  irritation  of  the  anus  sufficient  to  prevent 
healing,  and  therefore  should  be  arrested  by  the  use  of  a  teaspoon- 
ful  of  paregoric  every  time  the  bowels  act  until  stools  are  less 
frequent.  After  the  first  movement  of  the  bowels  the  stools  should 
be  kept  semifluid.  This  may  require  a  cathartic  at  intervals  of  not 
more  than  two  days.  During  the  first  week,  whenever  the  bowels 
are  about  to  move,  it  is  well  to  give  a  rectal  enema  of  eight  ounces 
of  olive  oil.  In  giving  the  enema  the  syringe-tip  should  be  passed 
carefully  along  the  posterior  wall  of  the  anus  away  from  the  anal 
sutures.  Carelessness  at  this  point  may  break  open  the  newly  united 
surfaces  and  destroy  the  result.  An  inexperienced  nurse  should  not 
be  permitted  to  give  the  enema. 

If  there  is  no  suppuration,  the  sutures  should  not  be  removed  until 
about  the  fourteenth  day.  In  other  respects  the  after-treatment  is 
the  same  as  for  incomplete  laceration. 

If  there  is  retention  of  urine  and  the  catheter  is  required,  one  may 
avoid  the  cystitis  which  sometimes  follows  catheterization  by  throwing  into 
the  bladder  tivo  drams  of  a  10  per  cent,  solution  of  argyrol,  and  leaving 
it  there  after  each  catheterization. 


CHAPTER    XLII. 

PUERPERAL  LACERATION  OF  THE  CERVIX  UTERI. 

The  credit  of  having  established  the  pathological  significance  and 
surgical  treatment  of  laceration  of  the  cervix  uteri  belongs  to  Emmet. 
His  three  original  communications  ^  not  only  contained  the  first  prac- 
tical information  on  the  subject,  but,  what  is  more  remarkable  when 
we  consider  the  great  frequency  and  the  far-reaching  pathological 
results  of  the  lesion,  the  information  which  they  contained  was  at 
once  so  complete,  so  accurate,  and  so  adequate  that  little  if  anything 
of  importance  has  been  added. 

Vague  allusions  to  the  subject  had  appeared  from  time  to  time 
before  the  publication  of  Emmet's  papers,  but  only  to  record  the  fact 
that  such  an  injury  could  result  from  parturition.  They  contained 
little  account  of  its  pathological  significance  and  none  of  its  surgical 
treatment.^ 

Causes  of  Laceration  of  the  Cervix  Uteri. 

The  causes  of  laceration  of  the  cervix  uteri  are  : 

1.  Relative  disproportion   in    size  between  the  child  and  the 

cervix. 

2.  Rigidity  of  the  cervix. 

3.  Rapid  second  stage  of  labor. 

4.  Any  disease  of  the  cervix  which  causes  friability  or  impairs 

elasticity. 

5.  Instrumentation. 

6.  Meddlesome  manipulation,  such  as  manual  dilatation  of  the 

cervix  to  hasten  labor. 
The  cervix  is  not  fully  prepared  for  dilatation  and  the  transmis- 
sion of  the  child  until  the  end  of  the  normal  period  of  gestation  ; 
hence  the  greater  liability  to  injury  in  premature  and  immature  labor. 
Abortion  in  the  earlier  months  of  pregnancy  is  not  a  frequent  cause 
of  laceration,  except  as  it  may  result  from  forcible  dilatation.^  ^  A 
greatly  prolonged  labor  may,  by  continued  pressure,  induce  nutritive 
changes,  and  thereby  decrease  the  elasticity  and  increase  the  liability 
to  rupture.     The  condition  is  an  approach  to  pressure-necrosis. 

1  "  Surgery  of  the  Cervix  Uteri."  American  Journal  of  Obstetrics,  February,  1S69.  "Lacera- 
tion of  the  Cervix  Uteri  as  a  Frequent  and  Unrecognized  Cause  of  Disease."  Ibid.,  Jsovem- 
ber,  1874.  "  The  Proper  Treatment  of  Lacerations  of  the  Cervix  Uteri."  American  Practitioner, 
January,  1877. 

-  The  Causes  and  Treatment  of  Sterility.  Gardener,  1856.  Cicatricial  Ectropion  of  the 
Cervix.    W.  Roser.    Archiv  fur  Heilkunde,  ii.  S.  97, 1861. 

565 


566 


TRAUMATISMS. 


Pathological  Anatomy  and  Results  of  Laceration  of  the 
Cervix  Uteri. 

At  the  outset,  let  the  important  fact  be  kept  clearly  in  mind  that 
the  injury  is  usually  more  extensive  in  the  surrounding  vaginal  struct- 
ures than  in  the  cervix  proper.  This  is,  perhaps,  contrary  to  the  usual 
notion ;  but  will  be  apparent  on  examination  of  later  paragraphs 
in  this  chapter  which  treat  of  the  state  of  the  cervix  before,  during, 
and  after  labor. 

FlGUBE  292. 


Vesico-uterine  fistula  at  angle  of  laceration.    The  fistulous  tract  has  been  left  after  partial 
healing  of  an  anterior  laceration. 

The  diameter  of  the  cervical  canal  in  the  non-pregnant  uterus  is 
about  one- fifth  of  an  inch.  This  must  be  increased  at  delivery  to 
correspond  to  the  diameter  of  the  child's  head  ;  it  is,  therefore,  not 
surprising  that  some  degree  of  laceration  occurs  in  the  majority  of 
labors.  The  lesion,  however,  is  generally  slight,  and  heals  so  readily 
and  rapidly  as  to  cause  little  or  no  pathological  result. 

The  Directions  and  Extent  of  cervical  laceration  vary  within  the 
widest  limits — /.  e.,  the  cervix  may  tear  in  any  direction  and  to  any 
extent.     The  usual  directions  are  :  anterior,  posterior,  and  lateral. 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI        567 

Anterior  and  posterior  lacerations,  especially  tlie  former,  usually 
heal  spontaneously,  and,  therefore,  seldom  are  observed.  This  heal- 
ing is  explained  by  the  anatomical  arrangement  of  the  vaginal  walls, 
which  tends  to  keep  the  torn  fragments  in  close  contact  while  union 
is  taking  place. 

Anterior  laceration  in  rare  instances  may  extend  so  far  as  to  invade 
the  bladder  and  make  a  vesico-uterovaginal  fistula.  In  such  a  case, 
if  attention  be  paid  to  cleanliness,  considerable  spontaneous  healing 
usually  follows.  There  may  be  left,  however,  a  small  vesicovaginal 
fistula  near  the  cervix  uteri,  or  a  vesico-uterine  fistula  at  the  angle 
of  the  laceration,  extending  from  this  part  of  the  cervical  canal 
into  the  bladder. 

Posterior  lacerations,  extending  into  the  posterior  vaginal  pouch, 
may  open  the  way  for  post-uterine  infection,  and  thus  give  rise  to 
contracting  cicatricial  bands  which  may  draw  the  uterus  downward 
and  backward,  and  fix  it  in  an  intractable  retroversion  or  retroflexion. 
A  variety  of  distressing  and  disabling  functional  disturbances,  includ- 
ing menstrual  disorders,  sterility,  and  extension  of  infection  to  the 
parametria  and  the  peritoneum,  are  among  the  results  which  may  be 
expected  from  this  condition. 

Lateral  lacerations  occur  most  frequently  to  the  left,  less  frequently 
to  the  right  and  left,  least  frequently  to  the  right  of  the  cervix. 

The  False  Cervix. 

Nature,  instead  of  repairing  the  injury  of  a  lateral  laceration, 
resorts  to  a  deception  so  artful  that,  until  explained  by  Emmet, 
the  lesion  had  been  practically  an  unknown  factor  in  uterine 
pathology.  By  this  deception  a  false  cervix,  composed  chiefly  of 
outrolled  intra-uterine  and  reduplicated  vaginal  tissue,  is  substituted 
for  the  normal  cervix.  The  evidence  of  laceration — that  is,  the 
irregular,  fissured,  uneven  appearance — is  so  obliterated  that  even  the 
practised  eye  may  fail  to  recognize  it.  If  diagnosis  between  the  nor- 
mal and  the  lacerated  cervix  were  solely  dependent  on  sight,  cases 
commonly  would  arise  in  which  increased  size,  congestion,  and  erosion 
would  be  the  only  diagnostic  signs. 

The  condition  of  the  cervix  before,  during,  and  after  labor,  as  laid 
down  in  the  following  statement,^  has  a  determining  influence  upon 
the  immediate  mechanical  results  of  laceration. 

Before  labor,  from  the  moment  of  the  pregnancy,  the  cervi-^,  as 
well  as  the  body  of  the  uterus,  enlarges  to  accommodate  the  growing 
foetus.  From  the  first,  the  entire  cervix,  except  a  small  part  which 
surrounds  the  external  os,  expands  symmetrically  with  the  body 
above.  This  expansion  early  in  pregnancy  obliterates  the  internal  os, 
and  converts  the  entire  cervix  into  an  inverted  dome,  which  projects 
into  the  vagina,  and  whose  walls  are  continuous  with  those  of  the 
corpus.  Thus,  long  before  term,  a  very  large  part  of  the  foetal  cover- 
ing is  composed  of  evolved  and  expanded  cervical  tissue. 

1  John  Bartlett.    Chicago  Medical  Journal,  October,  1873.     Wilhelm  Braune.    Atlas  of  Topo- 
graphical Anatomy,  Leipsic.    Translation.    Philadelphia,  1877. 


568  TBA  UMA  TISMS. 

During  labor  there  will  be  some  plane  in  the  cervix  above  which 
the  muscular  wall  of  the  uterus  contracts,  and  below  which  it  dilates, 
for  the  expulsion  of  the  child.  Examination  after  delivery  shows  a 
hard,  contracted,  unyielding  ring.  This  sometimes  has  appeared  to 
the  examiner  to  be  the  contracted  external  os.  It  is,  however,  above 
the  plane  of  the  external  os,  perhaps  even  above  the  uterovaginal 
attachment.  The  plates  of  Braune,  drawn  from  frozen  sections  of 
the  gravid  uterus,  show  the  remnants  of  the  internal  os  to  be  on  a 
plane  far  above  this  contracted  ring.  It  is,  therefore,  neither  the  con- 
tracted internal  os  nor  the  external  os,  but  is  situated  between  the  two, 
and  is  the  lowest  margin  of  the  contracted  part  of  the  uterine  wall. 
It  is  a  temporary  intracervical  os,  below  which  one  must  look  for  that 
part  of  the  cervix  which  during  labor  was  compelled  to  undergo 
excessive  dilatation ;  and  one  must  expect  there  to  find  laceration  if  it 
be  present. 

Without  care  this  lowest  part  of  the  cervix,  which  has  been  so 
stretched  that  it  cannot  recover  immediately  its  contractile  power, 
will  be  overlooked.  It  can,  however,  always  be  felt  projecting 
into  the  vagina  as  a  "  flabby,  floating  collar,"  not  unlike  a  "  sec- 
tion of  large  intestine,"  and  having  even  less  contractile  power  than 
the  sphincter  ani  muscle  after  extreme  forcible  dilatation. 

After  normal  labor  this  lowest  portion  of  the  cervix  slowly  recov- 
ers its  contractile  power,  and  in  a  few  days  resumes  its  normal  shape, 
and  the  integrity  of  the  external  os  thereby  is  restored. 

In  bilateral  laceration,  nature  has  especially  all  the  conditions  for 
the  formation  of  the  false  cervix  already  mentioned.  The  anterior 
and  posterior  diverging  flaps  of  the  cervix  are  forced  at  once  in  the 
directions  of  least  resistance  :  the  former  forward  toward  the  vaginal 
outlet,  the  latter  backward  into  the  posterior  vaginal  fornix.  The 
congested  tissues  about  the  temporary  os,  which  in  the  foregoing 
paragraph  has  been  called  intracervical,  meeting  no  resistance,  now 
roll  out.  This  eversion  gives  rise  to  obstruction  in  the  uterine  circu- 
lation. The  intracervical  structures,  thus  engorged  and  swollen,  no 
longer  have  sufficient  space  for  their  accommodation  within  the  uterus; 
hence  the  eversion  continues  until  tissue  enough  for  the  formation  of 
the  false  cervix  has  been  rolled  out  into  the  vagina,  and  until  the 
temporary  intracervical  os  actually  may  have  usurped  the  place  of 
the  now  destroyed  os  externum.  This  everted  intracervical  mucosa, 
when  rolled  out  into  the  hostile  environment  of  the  vagina  becomes 
infected,  and  the  infection  may  extend  along  the  mucosa  to  the  en- 
dometrium, Fallopian  tubes,  peritoneum,  and  ovaries ;  or  by  con- 
tinuity of  the  deeper  tissues  to  the  myometrium,  perimetrium,  or 
paranietrium.  Laceration  of  the  cervix,  therefore,  supplemented  by 
infection,  may  open  the  way  to  extensive  pelvic  disease. 

Subinvolution. — The  physiological  hypertrophy  of  pregnancy, 
which  ought  to  subside  after  labor,  under  the  influence  of  infection 
may  fail  to  do  so,  and  may  become  pathological.  Hence  the  uterus 
remains  enlarged  ;  this  enlargement,  called  subinvolution,  is  a  very 
common  result  of  laceration.  It  usually  pertains  more  to  the  cervix 
than  to  the  corpus  uteri.     See  Chapter  XVIII. 


PUERPERAL   LACERATION  OF  THE  CERVIX   UTERL         569 

Descent    and  Vaginal  Reduplication. — -When   the   patient  assumes 
the  upright  position  the  supports  of  the  lieavy  congested  subinvoluted 

Figure  293. 


The  widely  separated  lips  of  the  recently  lacerated  cervix.  The  posterior  lip  is  crowding 
backward  into  the  posterior  vaginal  fornix,  the  anterior  lip  forward  toward  the  vaginal  outlet. 
The  dotted  lines  show  the  contour  of  the  uterus  and  the  vagina  before  the  laceration.  The 
location  of  the  temporary  intracervical  os  is  at  the  bottom  or  angle  of  the  laceration. 

Figure  294. 


Shows  the  circular  enlargement  of  the  cervix  due  to  outrolling  of  the  intracervical  tissue, 
and  the  apparent  elongation  due  to  reduplication  of  the  vaginal  walls.  The  actual  utero- 
vaginal attachment  is  ai  X  and  Z.    The  reduplication  makes  it  appear  to  be  at  Y'  and  Z'.    See 


vaginal  attachment  is  ai  X  and  Z.    The  reduplication  makes  it  appear 
Figure  300. 

uterus  are  inadequate  to  hold  it  on  the  health  level ;  it  settles  by  its 
own  weight  to  a  lower  level  and  carries  with  it  a  reflected  fold  of  the 


570 


TRAUMATISMS. 


vaginal  wall.  See  Figures  297-299,  The  vaginal  portion  of  the 
cervix  thus  is  made  apparently  much  longer  than  it  really  is.  The 
soft,  easily  moulded  outrolled  intra-uterine  tissue  and  the  reflected 
vaginal  walls  may  obliterate  completely  the  fissure  which  is  re- 
garded commonly  as  the  evidence  of  laceration ;  upon  ordinary  exam- 
ination, therefore,  the  tear  may  be  overlooked  entirely.  The 
deception  may  be  exposed  by  placing  the  patient  in  the  knee-breast 
position.  The  uterus,  by  its  c^wn  weight,  will  be  carried  then  toward 
the  diaphragm ;  the  vaginal  wall  will  unfold  and  disclose  the  true 
uterovaginal  attachment;  and  not  uncommonly  a  deep  laceration  may 
be  seen  extending  on  either  side  far  into  the  vaginal  walls. 

FlGUKE  295 


False  cervix  in  unilateral  laceration.    Oblic[uity  of  the  uterine  axis  from  contraction  of 

broad  ligament. 


When  the  laceration  is  confined  to  one  side,  the  deception  of  the 
false  cervix  is  quite  pronounced,  for,  as  shown  by  Emmet,  the  fundus 
in  such  cases  usually  is  drawn  toward  the  aflPected  side  by  inflamma- 
tory contraction  of  the  nearest  broad  ligament.  The  effect  of  this 
lateroversion  is  to  raise  the  uninjured  side  of  the  cervix  a  trifle  higher 
in  the  pelvis,  and  correspondingly  to  depress  the  injured  side,  thereby 
causing  a  reflection  of  the  vaginal  wall  on  the  depressed  side,  so  that, 
as  in  the  bilateral  injury,  the  apparent  os  externum  may  seem  to  be 
in  the  very  centre  of  the  cervix  when  it  is  really  on  one  side.     To 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI        571 

add  to  the  confusion,  the  sound,  entering  at  the  side,  may,  though 
passing  to  the  horn  of  the  ojjposite  side  of  the  uterus,  appear  to  pass 
in  the  median  line.     Figure  295. 

Cystic  Degeneration. — Puerperal  laceration  of  the  cervix  uteri 
causes  marked  outroUing  of  intra-uterine  tissue  and  consequent  per- 
manent, passive  congestion.  The  delicate  intra-uterine  membrane, 
instead  of  being  in  contact  with  the  mild  alkaline  secretion  of  the 
uterus  to  which  it  is  accustomed,  is  in  contact  with  the  irritating  acid 
secretion  of  the  vagina.  But  the  mischief  does  not  end  here.  The 
uterine  supports  soon  may  prove  unequal  to  the  work  of  sustaining 
in  position  a  uterus  heavy  from  congestion,  and  the  uterus  falls  to  a 
lower  plane  in  the  pelvis.     The  everted  membrane,  in  contact  with 

Figure  296. 


Double  laceration,  showing  eversion  of  intra-uterine  mucosa  and  enlarged  mucous  follicles  on 

tiie  false  cervix. 

the  posterior  vaginal  wall,  and  constantly  bathed  in  the  vaginal  secre- 
tions, is  subject,  by  reason  of  the  normal  movements  of  the  uterus, 
to  the  additional  irritation  of  friction.  An  erosion  forms,  and  the 
mucous  follicles,  Nabothian  glands,  estimated  by  Tyler  Smith  to 
number  ten  thousand  in  the  normal  virgin  cervix,  become  diseased. 
Some  of  them  pour  out  the  familiar  thick,  viscid,  ropy,  or  purulent 
secretion.  Others,  in  consequence  of  adhesive  inflammation  which 
has  occluded  their  outlets,  become  distended  by  their  own  secretion 
and  undergo  cystic  degeneration.  Figure  296.  These  cysts  are  gen- 
erally present,  frequently  in  large  numbers.  Subinvolution,  includ- 
ing enlargement  of  the  uterine  blood-vessels,  is  a  natural  sequence  of 
these  changes. 


572 


TRAUMATISMS. 


Pathological  Anatomy  of  the  False  Cervix. — As  already  outlined, 
the  false  cervix  is  composed  of: 

Everted  intra-uterine  tissue. 

Reflected  vaginal  wall. 

Cervical  follicles  which  have  undergone  cystic  degeneration. 

Congested  and  inflamed  mucosa  and  submucosa. 

Enlarged  uterine  blood-vessels. 

Apparent  Hypertrophy  and  Elongation  of  the  False  Cervix. — Cases 

are  frequent  in  which  there  is  apparent  lengthening  of  the  cervix,  so 

that  it  seems  to  extend  from  the  uterovaginal  attachment  even  to  the 

vulva ;   the  condition  is  usually  described  as  hypertrophic  elongation 


FiGUKE  297. 


Figure  298. 


Figure  297.— This  Figure  is  from  a  part  of  an  illustration  in  a  standard  book,  in  which  it  was 
used  to  represent  supposed  iufravaginal  hypertrophy  of  the  cervix.  The  vaginal  attachment, 
however,  is  only  apparent,  and  is  due  really  to  reflection  of  the  vaginal  wall  on  a  lacerated  cer- 
vix. The  true  uterovaginal  attachment  is  shown  at  Jf  and  A' of  Figure  298.  Figure  298  is  a 
correct  representation  of  the  real  condition. 

Figure  298.— Shows  the  true  uterovaginal  attachment  at  JTand  X,  and  the  apparent  utero- 
vaginal attachment  at  Z  and  Z. 

of  the  cervix.  Credit  for  the  true  explanation  of  this  anomaly 
belongs  to  Emmet.  Figure  298  shows  the  os  externum  on  a  very  low 
plane.  This  is  not  because  the  iufravaginal  portion  of  the  cervix 
has  lengthened  by  hypertrophy  so  as  to  occupy  the  entire  length  of 
the  vagina,  but  because  the  entire  uterus  has  prolapsed,  carrying 
with  it  a  reduplicated  part  of  the  vaginal  wall,  until  the  os  externum 
has  appeared  at  or  near  the  vulva.  If  the  patient  be  placed  in  the 
knee-breast  position  and  the  uterus  be  made  to  gravitate  toward  the 
diaphragm,  the  reflected  vagina  will  be  unfolded,  the  cervix  will  resume 
its  normal  distance  from  the  vulva,  and  the  uterovaginal  attachment 
will  appear  at  the  proper  distance  from  the  os  externum — that  is,  the 
normal  relations  of  the  vagina  and  uterus  will  be  restored. 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI.        573 

Apparent  elongation  takes  place  occasionally  in  the  nullipara,  but 
it  is  associated  more  commonly  with  descent  of  the  lacerated  cervix. 
The  extent  of  laceration  will  be  apparent  in  proportion  to  the  degree 
of  eversion — that  is,  in  some  cases  the  evidence  of  laceration,  as 
already  explained,  is  obliterated  by  the  outrolled  intra-uterine  tissue  ; 
in  other  cases  of  less  eversion  the  laceration  is  more  apparent.  A 
striking  illustration  of  the  latter  class  of  cases  is  furnished  by  the 
following  case : 

The  patient  had  been  sent  to  the  hospital  for  amputation  of  a  sup- 
posed  "  hypertrophied    cervix."      Superficial   examination   suggested 

FlGTTRE  299. 


So-called  hypertrophic  elongation  of  the  supravaginal  portion  ot  tne  cervix— rare  except 
as  a  post-ojjerative  condition.  The  cervix  often  becomes  eluiigated  by  traction  during  the 
removal  of  it. 

the  presence  of  two  large  uterine  polypi,  one  filling  the  anterior  and 
the  other  the  posterior  half  of  the  vagina,  both  reaching  to  the  vulva ; 
further  examination  disclosed  the  apparent  presence  of  extreme  hyper- 
trophy of  the  anterior  and  posterior  lips  of  the  cervix.  Between 
these  two  lips  was  a  fissure  extending  into  the  vagina  for  at  least  two 
inches.  When  the  patient  was  placed  in  the  knee-breast  position, 
however,  the  uterus  gravitated  toward  the  diaphragm  ;  the  utero- 
vaginal attachment  appeared  in  its  true  relation,  and  it  was  plainly 
to  be  seen  that,  instead  of  hypertrophic  elongation  of  the  infra- 
vaginal  portion  of  the  cervix,  some  degree  of  atrophy  actually  had 
taken  place,  for  the  uterovaginal  attachment  was  nearer  to  the  exter- 
35 


574  TRAUMATISMS. 

nal  OS  than  normal.  There  was  a  fissure,  however,  disclosing  an  enor- 
mous bilateral  laceration,  which  extended  two  inches  into  a  subinvo- 
luted  uterus  and  far  out  into  the  vaginal  walls  on  either  side.  Repair 
of  the  cervix  was  followed  promptly  by  disappearance  of  all  apparent 
elongation,  both  in  the  infravaginal  and  supravaginal  portions  of  the 
cervix,  and  in  a  few  weeks  by  complete  subsidence  of  subinvolution. 
In  similar  cases  of  unilateral  laceration,  with  extreme  eversion,  the 
apparently  elongated  cervix  may  show  no  fissure,  but,  on  the  contrary, 
the  erosion  may,  as  before  stated,  give  to  it  a  symmetrical  form. 

Ampidation  of  the  cervix  and  hysterectomy  for  so-called  "  liyper- 
trophic  elongation  "  and  "  hypertrophic  enlargement  of  its  circumfer- 
ence" are  favorite  operations  in  gynecology.  The  true  pathology  of 
this  condition,  however^  would  demand  not  amputation  nor  hysterec- 
tomy, but  closure  of  the  cervix,  if  lacerated,  and  the  appropriate 
treatment  for  displacement. 

The  existence  of  genuine  hypertrophic  enlargement  and  elongation 
of  the  cervix,  although  not  absolutely  denied,  is  of  extremely  rare 
occurrence — so  rare  that  amputation  of  the  cervix,  except  the  removal 
of  certain  diseased  portions,  as  will  be  explained  in  the  operation  for 
lacerated  cervix,  should  become  practically  obsolete.  In  carcinoma 
of  the  cervix  and  in  extreme  intiammatory  infection  of  the  uterus, 
not  amputation  of  the  cervix,  but  hysterectomy  is  the  operation  of 
election. 

AVhen  hypertrophic  elongation  of  the  cervix  does  exist,  it  is  above 
the  uterovaginal  attachments,  and  is  therefore  supravaginal.  Infra- 
vaginal  elongation  of  the  cervix — that  is,  elongation  below  the  utero- 
vaginal attachment — is  often  apparent,  seldom  or  never  real. 

A  Cause  of  Carcinoma. — Emmet  first  observed  the  relatively 
more  frequent  development  of  cancer  upon  the  lacerated  cervix 
and  the  almost  entire  absence  of  it  from  the  nulliparous  cervix. 
While  we  may  not,  strictly  speaking,  attribute  cancer  to  laceration  of 
the  cervix,  we  must  not  ignore  the  fact  that  the  irritated  glands  of 
a  lacerated  cervix  are  a  fruitful  soil  for  malignant  disease. 

Symptoms  of  Laceration  of  the  Cervix  Uteri. 

Immediately  after  the  accident  occurs,  arterial  hemorrhage  may 
be  so  profuse  as  to  demand  prompt  ligature  and  suture.  The  second- 
ary symptoms  are  those  of  the  pathological  results  of  the  lesion — that 
is,  the  symptoms  of  endometritis,  metritis,  subinvolution,  and  dis- 
placements. The  menorrhagia  and  uterine  discharges  so  common  in 
laceration  are  the  symptoms  of  hemorrhagic  and  catarrhal  or  purulent 
endometritis.  A  variety  of  nervous  symptoms,  such  as  may  be  due 
to  faulty  innervation  and  nutrition,  have  been  attributed  to  laceration 
of  the  cervix.  They  include  neuralgic  and  other  pains  in  remote 
parts,  dyspepsia,  indigestion,  constipation,  menstrual  disorders,  back- 
ache, and  headache.  Bearing-down  sensations  and  difficulty  of  walk- 
ing and  standing  are  among  the  results  of  the  associated  displace- 
ments of  the  pelvic  floor.  These  displacements  include  the  uterus,  its 
appendages,  the  bladder,  vagina,  and  rectum. 


PUERPERAL   LACERATION  OF  THE  CERVIX   UTERL        575 

Cicatricial  narrowing  of  the  uterine  canal  at  tlie  angle  of  the  lacera- 
tion may  be  so  extreme,  either  from  natural  contraction  or  from  the 
use  of  caustics,  as  to  reduce  the  uterine  outlet  to  a  mere  pinpoint. 
This  reduction  of  calibre  results  in  imperfect  drainage  of  uterine 
secretions.  Endometritis  and  numerous  functional  disturbances,  in- 
cluding sterility,  dysmenorrhoea,  menorrhagia,  and  amenorrhoea,  are 
common  sequels. 

Emmet  lays  great  stress  upon  the  reflex  irritation  produced  by  the 
cicatricial  plug  in  the  angle  of  the  laceration.  The  cicatrix  develops 
in  an  effort  of  nature  to  close  the  gap,  or  as  a  result  of  the  injudi- 
cious application  of  caustics.  He  cites  numerous  cases  in  which 
severe  neuralgia  in  distant  organs — for  example,  neuralgia  in  the 
ayeball — promptly  disappeared  upon  repair  of  the  laceration.  He 
attributes  the  reflex  irritation  to  inclusion  and  pinching  of  nerve- 
filaments  in  the  cicatrix,  as  in  the  sensitive  stump  after  amputation 
of  the  leg  or  arm.  The  cicatrix,  therefore,  may  serve  as  a  constant 
and  hidden  cause  of  nerve  irritation.  Microscopical  study,  however, 
has  failed  to  disclose  the  pinched  nerve-filaments.  Whatever  may 
be  the  explanation  of  the  facts,  the  clinical  observations  of  Emmet 
apparently  have  been  verified  by  numerous  observers,  for  the  anaemic, 
nervous,  neuralgic  state  is  peculiarly  liable  to  be  associated  with  cica- 
tricial cervix. 

A  brief  report  of  two  cases  will  serve  to  illustrate  :  A  patient  con- 
sulted one  of  the  most  distinguished  ophthalmologists  in  America  for 
a  long-standing,  severe,  and  obstinate  neuralgia  of  the  eyeball.  As 
the  only  possible  means  of  relief  extirpation  of  the  eye  finally  was 
advised ;  this  operation  the  patient  declined,  and  the  pain  continued. 
She  subsequently  was  operated  upon  by  Emmet  for  laceration.  He 
removed  a  large,  wedge-shaped  piece  of  cicatricial  tissue  from  the 
angle  of  laceration,  which  nature,  in  the  vain  attempt  to  bridge  over 
the  gap,  had  placed  there.  Immediate  and  permanent  relief  from  the 
neuralgia  followed. 

In  April,  1878,  the  writer  performed  a  similar  operation  upon  a 
woman  who  had  for  years  suffered  from  almost  constant  pain  in  the 
top  of  the  head.  Up  to  the  time  of  the  operation  every  resource  of 
treatment  had  failed.  In  this  case  the  cervix  was  not  eroded,  but 
from  the  perseverance  of  some  one  in  making  caustic  applications  it 
had  suffered  considerable  loss  of  substance.  In  the  removal  of  the 
scar  tissue,  which  was  abundant,  a  large  part  of  the  cervix  was  sacri- 
ficed. The  pain  disappeared  from  the  time  of  the  operation  and  has 
not  returned. 

Clinical  observation  has  shown  sterility  and  repeated  abortion  to 
be  associated  very  frequently  with  laceration  of  the  cervix — an 
observation  for  which  the  pathological  results  of  laceration  already  as 
detailed  furnish  clear  explanation. 

Diagnosis  of  Laceration  of  the  Cervix  Uteri. 

Laceration  of  the  cervix,  until  demonstrated  by  Emmet,  was  known 
only  by  its  effects.  To  designate  the  extent  and  character  of  these 
effects,  the  following  names  were  applied  :  erosioji,  follicular  erosion, 


576 


TRAUMATISMS. 


granular  erosion,  papillary  erosion,  granulation,  excoriation,  ulcer. 
Erosions,  when  exaggerated,  were  called  coxcomb  granulations ;  when 
the  exaggeration  was  so  extreme  as  to  suggest  malignant  disease,  it 
sometimes  was  called  cauliflower  excrescence,  a  name  loosely  used  also 
to  designate  cancer.  Inflammation  of  the  cervical  follicles,  analogous 
to  follicular  pharyngitis,  suggested  the  name  follicular  erosion. 

The  older  text-books  usually  devoted  a  chapter  to  this  subject, 
under  the  head  of  Ulceration  of  the  Womb.  The  disease  is  really  not 
ulceration,  but  erosion.  Ulceration,  except  in  specific  and  malignant 
disease,  rarely  is  found  on  the  cervix. 

The  presence,  after  parturition,  of  a  part  or  all  of  the  elements 
which  compose  the  false  cervix — that  is,  enlargement,  erosion,  ever- 


FlGURE  300. 


Figure  301. 


Figure  300.— Showing  everted,  lacerated  lips  caught  by  tenacula  and  held  apart. 
Figure  301.— Showing  lacerated  lips  caught  by  tenacula  and  rolled  in. 

sion,  and  cystic  degeneration — is  strong  evidence  of  laceration  ;  cystic 
degeneration  of  the  mucous  follicles  is  almost  pathognomonic  of  lace- 
ration. The  cysts,  varying  in  size  from  that  of  a  pinhead  to  that 
of  a  small  marble,  feel  to  the  touch  like  shot  scattered  throughout 
the  mucous  tissues  of  the  everted  cervix.  They  rarely  are  found 
except  on  the  lacerated  cervix.  As  explained,  they  are  the  result  of 
occlusion  and  cystic  degeneration  of  mucous  follicles,  the  glands  of 
Naboth.  These  follicles,  except  in  cases  of  abnormal  distribution, 
are  confined  to  the  intracervical  mucous  membrane,  and  are  not  prone 
to  cystic  degeneration  unless  rolled  out  into  the  hostile  environment 
of  the  vaginal  secretions.  This  outrolling  seldom  occurs  except  as 
the  result  of  laceration.  Hence  cystic  degeneration  without  laceration 
is  rare. 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI.        577 

Laceration,  in  ordinary  cases,  may  be  detected  l)y  touch  and  sight. 
Intelligent  study  of  all  cases,  and  accurate  diagnosis  in  the  more 
obscure,  require  the  cervix  to  be  exposed  by  a  Sims  or  a  Simon  specu- 
lum (Sims  preferred),  and  the  everted  lips  to  be  caught  and  rolled  in 
by  means  of  two  uterine  tenacula,  one  in  each  hand. 

For  satisfactory  diagnosis,  in  many  cases  the  tenacula  are  essential. 
With  these  instruments  Emmet  was  first  to  solve  what  was  once  a 
knotty  problem,  and  to  revolutionize  the  pathology  .and  treatment  of 
this  cervical  disease.  Edmund  Randolph  Peaslee,  referring  to  the 
numerous  cases  of  so-called  ulceration,  said^  "they  were  not  recog- 
nized, for  none  of  us  knew  anything  about  them  till  Emmet  told  us. 
It  was  he  who,  in  a  happy  moment,  brought  the  anterior  and  posterior 
surfaces  together  with  tenacula,  and  instantly  demonstrated  that  what 
we  all  supposed  an  ulceration  was  nothing  more  nor  less  than  a  lace- 
ration."    Figures  300  and  301. 

I  quote  somewhat  fully  from  Emmet's  first  systematic  paper  on 
this  subject^  because  it  presents  a  graphic  picture  of  the  gynecology 
of  the  last  generation,  and  because  of  the  historical  importance  of  this 
epoch-making  contribution  to  surgical  literature  : 

"November  27,  1862,  I  first  operated  for  the  relief  of  a  double 
lateral  laceration  of  the  cervix  by  freshening  the  surfaces  and  bringing 
together  the  anterior  and  posterior  flaps  with  interrupted  silver 
sutures.  This  patient  had  been  an  invalid  for  several  years  before 
coming  under  my  care,  and  had  been  treated  for  menorrhagia  and 
hypertrophy  of  the  uterus,  with  an  extensive  erosion.  She  was  under- 
size,  of  a  naturally  delicate  constitution,  and  after  a  severe  and  pro- 
tracted labor,  with  difficulty  had  given  birth  to  a  large  child.  Her 
general  appearance  indicated  incipient  phthisis,  but  no  evidence  of  a 
tuberculous  deposit  could  be  detected.  The  uterus  was  some  four 
inches  in  depth,  and  an  erosion  extended  about  two  inches  in  diam- 
eter over  an  enormous  cervix.  With  ffreat  care  this  erosion  had 
been  healed  several  times,  by  maintaining  the  recumbent  position 
for  a  sufficient  length  of  time,  but  a  relapse  to  the  former  condition 
recurred  in  every  instance  shortly  after  beginning  to  exercise  by 
walking.  I  had  almost  despaired  of  being  able  to  offer  her  any 
permanent  relief,  and  attributed  my  want  of  success  to  the  condition 
of  her  general  health.  While  making  a  digital  examination  one  day 
I  was  puzzled  to  account  for  the  greater  width  of  the  cervix  in  com- 
parison to  that  of  the  body  beyond,  a  condition  I  had  for  the  first  time 
appreciated.  I  placed  her  on  the  left  side  and,  with  Sims'  speculum, 
brought  the  cervix  in  view.  I  drew  the  posterior  lip  forward  toward 
me  with  a  tenaculum,  but  with  no  special  purpose,  when  I  was  sur- 
prised to  observe  that  it  had  decreased  to  nearly  half  its  previous  size. 
On  lifting  up  the  anterior  lip  with  a  tenaculum  in  the  other  hand,  so 
as  to  bring  the  two  portions  into  approximation,  the  outline  of  a  cer- 
vix presented,  of  nearly  normal  size.  The  difficulty  was  at  once  appar- 
ent, for  the  parts  had  rolled  back  within  the  uterine  canal,  and  a  deep 

1  Remarks  after  the  reading  of  a  supplementary  paper  on  "  The  Proper  Treatment  of  Lacera- 
tion of  the  Cervix  Uteri,"  by  Emmet,  before  the  New  York  County  Medical  Society,  December, 
1876.    New  York  Medical  Journal,  January,  1877. 

2  "  Laceration  of  the  Cervix  Uteri  as  a  Frequent  and  Unrecognized  Cause  of  Disease."  Ameri- 
can Journal  of  Obstetrics,  November,  1874. 


578  TRAUMATISMS. 

lateral  fissure  became  evident,  which  extended  on  each  side  entirely 
through  the  cervix  and  beyond  the  vaginal  junction.  On  separating 
the  flaps  and  forcuig  them  back  to  their  former  position,  I  saw  the 
tissues  gradually  roll  out,  and  the  cervix  again  present  its  previous 
appearance.  There  could  then  be  detected  no  appearance  of  laceration, 
and  with  the  reduplication  of  vaginal  tissue  over  the  sides  of  the 
uterus,  the  cervix  presented  a  normal  length  above  its  apparent 
junction  with  the  vagina.  The  remedy  at  once  suggested  itself; 
the  operation  was  performed  with  the  aid  of  my  assistant,  Dr.  G.  S. 
Winston,  and  I  believe  Dr.  T.  G.  Thomas  was  also  present.  On 
completing  the  operation  the  uterus  was  five  inches  in  depth ;  it 
rapidly  reduced  in  size,  and  in  time  all  evidence  of  local  disease 
subsided,  but  she  never  entirely  regained  her  general  health.  Some 
seven  years  after  the  operation  Dr.  F.  N.  Otis,  of  New  York,  her 
family  physician,  detected  a  tuberculous  deposit,  and  she  died  of 
phthisis  within  a  few  months,  having  been  ten  years  under  my  obser- 
vation. For  two  years  previous  to  her  death  she  had  resided  abroad, 
but,  as  a  friend,  I  was  kept  advised  of  her  condition,  and  she  con- 
tinued free  from  uterine  disease.  I  am  fully  satisfied  that  at  the  time 
of  the  operation  her  condition  was  so  critical  that  it  would  have  been 
but  a  question  of  a  few  weeks  before  a  tuberculous  deposit  would  have 
taken  place.  Although  she  never  recovered  fully  the  loss  of  vitality 
to  which  this  injury  had  reduced  her,  yet  her  life  was  beyond  question 
prolonged  many  years  by  the  operation." 

After  the  reading  of  this  paper  before  the  New  York  County 
Medical  Society,  September,  1874,  J.  Marion  Sims  said  : 

"  When  I  went  abroad  in  1862,  among  the  patients  I  turned  over 
to  the  care  of  Dr.  Emmet  was  the  lady  whose  case  forms  the  basis  of 
the  paper  I  have  just  read.  She  belonged  to  the  upper  walks  of  life, 
and  had  been  under  my  charge  for  twelve  or  eighteen  months.  I 
remember  the  peculiarities  of  her  case,  so  well  described  by  Emmet, 
as  vividly  as  if  it  were  but  yesterday.  The  bilateral  lacerations  of 
the  cervix,  and  the  consequent  eversion  of  the  hypertrophied,  con- 
gested cervical  mucous  membrane,  constituted  at  that  time  a  difficult 
problem  to  solve.  During  the  whole  time  that  I  observed  this  case 
no  benefit  resulted  from  local  treatment,  and  I  am  sure  that  nothing 
short  of  the  method  so  successfully  adopted  by  Dr.  Emmet  could 
have  been  of  the  least  service  to  her.  I  now  only  wonder  that  this 
operation  had  not  been  worked  out  sooner.  When  the  perineum  is 
lacerated,  the  necessity  for  its  reconstitution  is  self-evident,  and  it  is 
singular  that  the  necessity  for  reconstituting  the  integrity  of  a  lacer- 
ated cervix  did  not  sooner  force  itself  upon  the  surgeon.  The  opera- 
tion as  devised  and  practised  by  Dr.  Emmet  is  as  simple,  as  safe,  and 
as  certain  in  its  results  as  is  the  operation  for  a  simple  case  of  vesico- 
vaginal fistula.  The  same  principles  underlie  each.  The  same  free 
denudation  of  tissue,  the  same  method  of  suture,  the  same  after-treat- 
ment, and  the  same  security  from  danger  belong  to  both  alike. 

"  I  have  performed  the  operation  often  enough  to  speak  in  positive 
terms  of  its  value.  The  discussion  of  the  subject  must,  of  necessity, 
be  one-sided.     There  can  be  no  objection,  no  opposition  to  the  opera- 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI        579 

tion.  We  must  accept  it  as  Dr.  Emmet  has  given  it  to  us.  We  can- 
not modify  the  operation  ;  we  cannot  change  it ;  we  cannot  improve 
it — for  it  is  perfect ;  perfect  in  its  method  and  perfect  in  its  results. 

"We  owe  to  Dr.  Emmet  a  debt  of  gratitude  for  this  vahiable  con- 
tribution to  uterine  surgery.  Like  all  new  operations,  it  is  likely  to 
be  abused ;  but  the  time  will  soon  arrive  when  it  will  assume  its  place 
in  the  foremost  rank  of  useful  improvements." 

Differential  Diagnosis  of  Laceration  of  the  Cervix  Uteri. 

Laceration  of  the  cervix  uteri  is  to  be  distinguished  specially  from  : 

1.  Endocervicitis. 

2.  Congenital  eversion. 

3.  Cancer. 

There  is  a  form  of  erosion  due  to  endometritis,  associated  with  an 
irritating  discharge  from  the  endometrium  or  vagina,  apt  to  occur  in 
feeble  and  poorly  nourished  subjects,  and  not  very  uncommon  in  vir- 
gins ;  the  condition  is  analogous  to  the  familiar  erosion  and  excoriation 
produced  by  prolonged  nasal  discharges  on  the  upper  lips  of  children. 
Such  an  erosion  is  distinguished  readily  from  that  of  laceration  by 
absence  of  eversion,  by  the  absence  of  marked  cervical  enlargement, 
by  the  presence  of  a  normally  shaped  os  externum,  and  by  physical 
examination  soon  to  be  described.  The  treatment  is  that  of  the  causa- 
tive endometritis. 

Congenital  eversion  of  the  non-lacerated  cervical  mucosa  may  occur 
in  rare  cases.     It  has  been  observed  even  in  infancy.^ 

The  disease  most  liable  to  be  mistaken  for  laceration  is  beginning 
cancer  of  the  cervix.  A  careful  reading  of  the  description  of  this 
disease  will  help  to  show  the  difference  between  the  two  conditions. 
Cancer  bleeds  freely  on  slight  abrasion,  is  extremely  friable,  does  not 
readily  permit  inrolling  with  tenacula,  and  rapidly  goes  on  to  ulcera- 
tion.    Laceration  presents  none  of  these  characteristics. 

Prophylaxis  of  Laceration  of  the  Cervix  Uteri. 

The  prophylaxis  consists  in  the  avoidance  of  all  measures  calcu- 
lated to  hasten  unduly  the  normal  progress  of  labor — that  is,  the  avoid- 
ance of  meddlesome  manipulations  by  digital  or  instrumental  inter- 
ference. A  precipitate  labor  should,  if  practicable,  be  retarded.  The 
relative  disproportion  between  the  child  and  the  cervix  may  render  all 
precautions  useless  and  laceration  inevitable. 

Treatment  of  Laceration  of  the  Cervix  Uteri. 

The  Operation  of  Trachelorrhaphy.^ — It  is  not  necessarily  the 
extent  of  laceration,  but  rather  the  degree  of  outrolling  that  indicates 
the  necessity  for  repair.  A  relatively  slight  laceration  may  give  rise 
to    extreme    eversion,    and  consequently    to    all  of   the    pathological 

»  Noble.    American  Gynecological  and  Obstetrical  Journal,  February,  1897. 

2E  C  Dudley  of  Chicaso,  former  interne  at  the  Woman's  Hospital  in  the  State  of  New- 
York,  was  the  first  to  designate  this  operation  trachelorrhaphy.  Emmet's  Principles  and 
Practice  of  Gynecology. 


580  TRAUMATISMS. 

changes,  above  described,  which  belong  to  the  false  cervix.  Fur- 
thermore, slight  laceration  without  aversion  may,  if  associated  with 
great  cicatricial  formation  or  cystic  degeneration,  give  rise  to  very 
distressing  symptoms.  On  the  other  hand,  a  deep  laceration  may 
cause  little  or  no  disturbance. 

Immediate  Operation  of  Trachelorrhaphy. — Some  obstetricians  urge 
immediate  closure  of  the  torn  cervix  uteri.  This  operation,  if  suc- 
cessful, would  have  the  same  advantages  as  immediate  perineorrhaphy 
— that  is,  less  danger  of  infection  through  the  exposed  surfaces,  relief 
from  long-continued  dread  of  operation,  and  freedom  from  the  evil 
effects  of  any  pathological  changes  consequent  upon  delay.  There  is, 
however,  great  difficulty  in  recognizing  the  limit  of  the  fresh  tear  in 
the  loose  folds  of  the  divulsed,  soft,  flabby  cervix  and  the  surround- 
ing upper  end  of  the  vagina.  The  exact  relations  of  the  torn  vaginal 
wall  to  the  cervix  are  also  difficult  to  define  ;  for  these  reasons  accu- 
rate adjustment  of  the  torn  surfaces  may  be  difficult.  The  immediate 
operation,  therefore,  unless  necessitated  by  profuse  arterial  hemor- 
rhage, is  of  questionable  propriety  ;  when  it  is  performed,  the  con- 
tinuous catgut  suture  should  be  used. 

Secondary  Operation  of  Trachelorrhaphy. — In  order  to  avoid  outroil- 
ing,  subinvolution,  cystic  degeneration,  endometritis,  metritis,  descent 
and  other  pathological  changes,  early  repair  of  the  extensively  torn 
cervix  is  desirable.  The  operation  is  permissible  as  soon  as  the  cer- 
vix has  recovered  from  the  immediate  effects  of  extreme  divulsion, 
and  has  regained,  so  far  as  the  injury  will  permit,  its  normal  form — 
that  is,  at  the  end  of  two  or  three  months.  Unfortunately,  in  the 
majority  of  cases,  the  lesion  is  not  recognized  or  brought  to  the  atten- 
tion of  the  gynecologist  until  the  resultant  pathological  changes  have 
impaired  seriously  the  health  of  the  patient.  It  is  the  duty  of  the 
accoucheur,  and  is  one  of  the  imperative  requirements  of  modern 
scientific  midwifery,  to  make,  in  the  second  or  third  week  of  the 
puerperium,  an  examination  of  the  pelvic  organs  to  determine  the 
existence  of  any  pathological  condition  which  may  demand  attention. 

Preparatory  Treatment  of  complicating  displacements  and  erosions, 
although  advised  by  many,  is  not  usually  imperative.  The  treatment 
of  a  displacement  may  be  necessary  after  the  operation,  and  may 
be  deferred  properly  to  that  time.  Associated  endometritis  should  be 
treated  by  preliminary  curettage  as  a  preparatory  step  in  the  opera- 
tion for  closure  of  the  laceration.  If  tHe  eroded  cervix  be  greatly 
thickened  or  complicated  by  extensive  cystic  degeneration,  the  dis- 
eased tissues  should  be  removed  by  Schroeder's  method.  Figures 
309-312. 

It  is  difficult  to  discriminate  between  certain  inflammatory  condi- 
tions in  the  pelvis  which  contraindicate  and  others  which  indicate 
trachelorrhaphy.  The  operation,  if  performed  in  a  case  of  acute  pelvic 
inflammation  or  of  suppurative  inflammation,  acute  or  chronic,  is 
liable  to  be  followed  by  general,  possibly  fatal,  pelvic  infection,  and 
therefore  is  contraindicated.  The  presence,  in  the  pelvis,  of  structures 
which  are  thickened,  hypersensitive,  or  adherent — or,  in  other  words, 
the  non-purulent    results  of  chronic  inflammation — does  not  neces- 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI        581 

sarily  contraindicate  Emmet's  operation.  On  the  contrary,  the  im- 
proved uterine  drainage  secured  by  the  preliminary  dilatation,  the 
removal  of  the  products  of  endometritis,  and  of  the  original  source 
of  the  pelvic  infection  by  thorough  curettage  of  the  inflamed  endo- 
metrium, and  the  rolling,  in  of  the  irritable  everted  cervical  mucosa, 
may  be  the  most  effective  treatment  for  such  pelvic  inflammation. 

Puncturing  of  Cysts. — The  follicular  retention-cysts  already 
described,  if  present,  will,  unless  properly  treated,  render  the  operation 
for  closure  of  the  cervix  not  only  useless,  but  also  injurious.  In  fact, 
these  diseased  glands  if  rolled  into  the  cervical  canal  by  trachelorrhaphy 
are  liable  to  enlarge,  multiply,  and  remain  a  hidden  source  of  irrita- 
tion. Often  they  are  so  numerous  and  of  such  large  size  as  to  lead 
to  the  suspicion  of  cancer.  If  few  in  number  and  superficial,  they 
may  be  punctured,  or  the  projecting  part  of  the  cyst-wall  may  be 
caught  with  a  tenaculum  and  removed  by  the  scissors  and  the  re- 
maining part  of  the  cyst-wall  then  destroyed  by  nitric  acid  or  the 
galvanocautery.  Several  such  treatments  may  be  required  before  the 
cervix  is  ready  for  operation.  Extensive  cystic  development,  espe- 
cially on  the  thickened  cervix,  extending  up  into  the  cervical  canal, 
requires  excision  of  the  diseased  tissue.  Simple  puncturing  of  the 
cysts  by  the  spear-pointed  lance  is  inadequate  because,  unless  the 
secreting  surface  be  destroyed,  the  cysts  are  prone  to  refill.  See 
Schroeder's  operation.     Figures  309-312. 

Instruments  for  the  Operation. — The  following  instruments  are 
required : 

Sims'  speculum  and  depressor,  or  Simon's  retractor. 

Two  uterine  tenacula. 

Emmet's  uterine  dressing-forceps. 

Emmet's  slightly  curved  and  full-curved  scissors. 

Emmet's  needle-forceps. 

Short  hsemostatic  forceps. 

Needles. 

Four  sponge-holders. 

Grauze  or  sea  sponges. 

Silkworm  gut  and  chromic  catgut. 

Rubber  sheet  or  Kelly's  pad. 

Flat  vulsellum  forceps. 

Instruments  for  dilatation  and  curettage. 
Many  operators  prefer  the  Simon  to  the  Sims  speculum  ;  the  writer 
uses  either  indifferently.  The  majority  of  surgeons  probably  prefer 
Simon's  retractor  to  Sims.'  Education  and  habit  will  fix  the  choice, 
which  should  be  limited  to  these  two  instruments.  The  needle  with 
bayonet  trocar,  or  glover's  point,  is  preferable  to  that  with  the  round 
point ;  the  latter  is  difficult  to  introduce  through  the  indurated  tissue 
without  breaking.  The  full-curved  needle  is  unmanageable  ;  the  force 
required  for  its  introduction  is  exerted  in  the  line  of  a  tangent  to  the 
curve,  and  is  therefore  more  liable  to  break  the  needle  than  when 
exerted  in  the  direct  line  of  the  straight  needle.  It  may  also  be  diffi- 
cult to  estimate  the  location  of  the  point  of  a  curved  needle.  There 
are  practical  advantages  in  a  needle  slightly  curved  at  the  point,  but 
otherwise  straight. 


582 


TRAUMATISMS. 


Disinfection. — The  antiseptic  measures  to  an  aseptic  result  have 
been  detailed  in  Chapters  II.  and  V.  Under  anaesthesia  the  patient 
being  on  her  back,  the  vaginal  and  external  genitals  are  scrubbed 
thoroughly  with  water  and  green  soap.  When  the  soap  has  been  washed 
off  with  hot,  sterilized  water,  the  disinfection  is  completed  by  an  addi- 
tional washing  with  a  1 :  2000  alcoholic  solution  of  bichloride  of  mer- 
cury. A  conjoined  examination  is  made  now  in  order  to  obtain  in- 
formation of  any  condition  which  before  anaesthesia  may  have  been 

Figure  302. 


Manner  of  denudation  with  uterine  tenaculum  and  Emmet's  curved  scissors.  One  side  denuded, 
trie  other  partly  denuded.    Left  lateroprone  position ;  exposure  by  Sims'  speculum. 

overlooked.  This  examination,  since  it  occasionally  reveals  condi- 
tions which  may  modify  or  contraindicate  the  operation,  is  important. 
If  no  contraindication  for  the  operation  appears,  the  cervix  is  exposed 
by  Sims'  or  Simon's  speculum,  and  the  uterus  dilated,  curetted,  washed 
out,  and  treated  with  an  intra-uterine  application  of  a  saturated  solu- 
tion of  iodine  in  95  per  cent,  carbofic  acid,  which  disinfects  the 
endometrium  and  decreases  the  risk  of  infection. 

Preliminary  Dilatation  and  Curettage  may  be  required  only  for  the 
purpose  of  exploration,  in  order  to  determine  the  presence  or  absence 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERL        583 

of  complicating  endometritis.  The  objects  of  dilatation  and  curettage 
are :  1,  to  prevent  infection  of  the  wound  and  failure  of  union  from  con- 
tact of  the  pathological  secretions  of  a  possibly  diseased  endometrium  ; 
2,  to  secure  efficient  drainage  of  the  endometrium,  and  thereby  to  pre- 
vent the  retention,  stagnation,  decomposition,  and  absorption  of  its 
st'cretions  ;  3,  to  avoid  leaving  an  infected  endometrium,  which,  after 
closure   of  the   cervix,  might  by  extension  involve   the    parametria, 

Figure  303. 


Shows  the  surface  denuded  and  two  sutures  in  place,  but  not  tied.    Left  lateroprone  position ; 
exposure  by  Sims'  speculum. 


uterine  appendages,  and  peritoneum,  in  disabling  or  dangerous  infec- 
tion. 

Approximation. — Before  proceeding  to  the  closing  of  the  cervix,  a 
careful  study  should  be  made  of  the  direction  or  directions  and  extent 
of  the  rupture,  by  trial  approximations  of  the  torn  fragments  in 
various  ways  witha  tenaculum  in  each  hand.  If  there  be  a  simple 
bilateral  laceration,  the  operation  will  be  as  follows  : 

Denudation. — With  the  tenaculum  and  curved  scissors  the  surfaces 
to  be  united  are  denuded.  Figure  302.  Inasmuch  as  one  of  the  im- 
portant functions  of  the  uterus  is  drainage^  it  is  essential  to  leave  a 
wide  and  free  outleb  at  the  external  os.     To  this  end,  that  portion  of 


584 


TRAUMATISMS. 


the  undenuded  mucosa  which  is  to  line  the  restored  external  os  should 
be  left  wide,  so  that  when  united  the  normal  trumpet-shape  of  the 
lower  segment  of  the  cervical  canal  will  be  preserved.  Immediately 
after  the  operation  the  diameter  of  the  restored  external  os  should  be 
even  larger  than  normal,  so  that  the  involution  that  follows  the 
operation  will  reduce  it  ultimately  to  the  normal  calibre.  Figures 
303  and  304  show  the  properly  curved  lines  between  the  denuded 
and  undenuded  surfaces.  Extreme  stenosis  at  the  external  os,  some- 
times amounting  to  complete  atresia,  is  a  possible  result  of  inattention 
to  this  important  detail. 

Among  the  consequences  of  stenosis  and  obstruction  in  the  uterine 
canal  are  the  following  : 

1.  Retention  and  decomposition  of  uterine  secretion  and  men- 
strual fluid. 

2o  Possible  destruction  of  the  Fallopian  tubes. 

3.  Metritis,  endometritis,  and  salpingitis. 

Figure  304. 
A^ ^Cf 


A  line  connecting  Y,  X,  and  Z  would  represent  angle  of  laceration ;  X,  section  of  uterine  canal 
at  angle  of  laceration.    Three  of  the  sutures  in  place.    Diagrammatic. 


The  conditions  mentioned  above  may  give  rise  to  immediate  disas- 
trous results,  or  may  cause  persistent  invalidism.  The  rapid  and  com- 
plete relief  which  often  follows  the  reopening  of  a  contracted  cervical 
canal  and  os  externum  proves  that  the  integrity  of  the  uterine  canal 
as  a  natural  drainage-tube  is  essential  to  health. 

Removal  of  the  Cicatricial  Plug. — The  denudation  should  always 
include  removal  of  the  plug  of  cicatricial  tissue  which  usually 
forms  the  angle  of  the  laceration.  This  important  step  in  the 
operation,  if  disregarded,  may  prevent  easy  approximation  of  the 
denuded  surfaces,  cause  the  sutures  to  cut  out  from  undue  tension,  and 
result  in  failure  of  union  or  in  imperfect  union.  Failure  of  union, 
however,  under  such  conditions  would  be  a  fortunate  compromise  for 


PUERPERAL  LACERATION  OF  THE  CERVIX    UTERI        585 

the  patient,  since  the  cicatrix  is  much  less  injurious  with  the  laceration 
open  than  closed.     When^  unfortunately,  union  has  taken  place,  the 

Figure  305. 


Sutures  in  place  on  one  side  ready  to  tie.    Diagrammatic. 

consequent  train  of  nervous  symptoms  may  necessitate  reopening  of 
the  wound  and  removal  of  the  cicatricial  plug. 

Hemorrhage. — The  usual  slight  bleeding  is  controlled  readily  by 
sponge  pressure.  Arterial  hemorrhage,  if  not  controlled  by  forci- 
press'ure  or  torsion,  may  require  a  fine  catgut  ligature.  In  occasional 
aggravated  cases  the  bleeding  must  be  checked  by  the  application  of 
one  or  two  deep  sutures.  _ 

The  Sutures  may  be  of  chromic  catgut  or  silkworm  gut.  bilk- 
worm  gut  remains  aseptic  longer,  and  is  therefore  superior  to  catgut. 
If  the  perineum  is  closed  at  the  same  time,  the  difficulty  in  the 
removal  of  the  cervical  sutures  will  justify  the  use  of  absorbable  cat- 
gut, which  does  not  have  to  be  removed.  Catgut  may  also  be  used 
in  the  repair  of  all  small  lacerations,  especially  where  the  surfaces 
readily  fall  together  and  remain  in  apposition  without  traction.  The 
catgut  should  be  so  chromicized  that  it  will  resist  absorption  for 
twenty  days.  In  order  that  the  sutures  may  not  convey  possible 
infection  to  the  wound,  they  should  in  all  plastic  surgery,  so  far  at. 
practicable,  be  passed  under  and  not  through  the  denuded  surfaces. 
This  principle  is  illustrated  by  the  dotted  lines  in  Figure  304;  the 
surface  between  the  lines  AB  and  CD  is  left  undenuded,  to  form 
that  part  of  the  cervical  canal  which  is  to  be  restored.  The  two 
sutures  indicated  on  one  side  show  the  location  of  the  sutures  near  the 
angle  of  laceration ;  and  the  one  on  the  opposite  side  shows  the 
location  of  the  sutures  at  the  os  externum.  When  all  the  sutures  have 
been    tied,  they   will   bring    the    surface  AYXZC  in   contact  with 


5S6,  TRAUMATISMS. 

the  surface  BYXZD  in  such  a  manner  that  point  A  will  coincide  with 
point  B,  and  point  C  with  point  D.  The  lines  A  C  and  BD  will  then 
bound  the  restored  external  os. 

Figure  305  shows  the  same  laceration  from  another  point  of  view. 
The  sutures  on  one  side  are  represented  as  all  having  been  introduced 
before  any  are  tied.  This  was  the  plan  formerly  pursued  when  the 
silver  suture  was  used.  It  is  better  to  tie  the  silkworm  gut  or  catgut 
sutures  as  they  are  introduced. 

Figure  306  shows  the  sutures  tied,  the  everted  mucosa  rolled  in, 
and  the  operation  complete. 

A  study  of  Figures  305  and  306  will  disclose  an  interesting  fact  in 
the  mechanics  of  laceration  and  trachelorrhaphy.  If  in  the  subinvo- 
luted  uterus  represented  by  Figure  305  the  distance  from  the  angle  of 
laceration^  X,  to  the  fundus  is,  say,  three  inches,  and  the  distance  from 

FiGUKE  306. 


Showing  the  rolling-in  effect  of  the  operation.    Sutures  tied.    Diagrammatic. 

the  angle  of  laceration  to  the  margin  of  the  torn  lip  is  one  inch,  it 
would  appear  reasonable  to  assume  that  the  uterine  canal,  when  fully 
restored,  would  measure  four  inches.  Accurate  measurements  of  the 
uterine  canal,  howevet,  before  and  after  operation  almost  always  show 
a  decrease,  not  an  increase,  in  length.  In  a  uterus  of  such  dimen- 
sions, the  canal,  after  operation,  usually  would  measure  not  four,  but 
about  two  and  three-quarters  inches.  The  explanation  of  this  decrease 
is  as  follows : 

As  shown  in  the  pathology,  the  intra-uterine  mucosa  rolls  out,  and 
the  lowest  portion  of  the  uterine  canal  becomes  the  external  os  of  the 
lacerated  cervix,  point  X,  Figure  306.  In  tying  the  first  suture 
points  ]  and  1  are  not  only  ])rought  together  to  form  one  and  the 
same  point,  but  all  mucosa  above  this  suture  is  at  the  same  time  rolled 
into  the  uterine  canal,  so  that  point  X  moves  up  and  point  1  takes  its 
place.     On  the  successive  tying  of  the  other  sutures,  2,  3,  4,  and  5, 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI        587 

the  same  mechanical  result  is  observed,  so  that  finally  suture  5,  Avhen 
tied,  occupies  the  place  formerly  occupied  by  X.  All  the  mucosa 
between  1  and  5  on  one  side,  and  1  and  5  on  the  other,  is  now  rolled 
into  the  uterine  canal  above  the  original  level  of  point  X.  This 
mechanical  result  alone  abundantly  justifies  the  operation  ;  it  also 
verifies  the  propositions  laid  down  in  tlie  preceding  paragraphs  on  the 
mechanical  results  of  the  lesion. 

The  reasons  for  so  great  a  decrease  in  the  length  of  the  uterine 
canal  may  not  be  wholly  apparent  from  the  foregoing.  The  following 
reasons,  in  addition  to  the  rolling-in  of  the  everted  tissue,  are  there- 
fore submitted  :  loss  of  blood  and  tissue  in  denuding ;  evacuation  or 
removal  of  retention-cysts ;  contraction  of  muscular  fibre  due  to  the 
stimulus  of  the  operation  ;  and,  above  all,  relief  from  congestion,  which 
naturally  follows  restoration  of  everted  intra-uterine  structures  to  their 
normal  position  inside  of  the  uterus.  The  outrolled  structures  before 
the  operation  had  been,  so  to  speak,  in  a  state  of  erection. 

Operation  for  Atypical  Lacerations. — The  closure  of  a  uni- 
lateral, anterior  or  posterior  laceration  follows  the  rules  already  down 
for  simple  bilateral  injuries.  Stellate  lacerations  in  some  cases  may 
be  treated  by  closure  of  each  individual  tear;  or,  if  two  are  very  near 
together,  they  may  be  changed  into  one  by  removal  of  the  inter- 
vening tissue.  There  may  be  one  or  two  major  and  several  minor 
rents ;  in  such  a  case  the  surgeon  sometimes  may  disregard  the  small 
fissures,  and  by  rolling  in  the  everted  cervix,  as  indicated  by  the 
deeper  tears,  find  that  the  smaller  ones  disappear  within  the  canal, 
and  may  therefore  be  ignored  in  the  operation.  It  is  impossible  to 
anticipate  every  variation  in  the  direction  and  effect  of  the  injury. 
Each  atypical  case  must  be  treated  according  to  the  special  require- 
ments. 

Resection  of  the  Cervix. — In  a  large  proportion  of  cases  of 
laceration  of  the  cervix  the  lesion  is  unrecognized,  neglected,  or 
unskilfully  treated,  so  that  extensive  pathological  changes  occur. 
These  changes  may  prevent  or  contraindicate  the  rolling-in  of  the 
diseased  tissues;  or,  if  the  cervix  has  been  closed  improperly,  may 
require  it  to  be  reopened  and  closed  again  correctly.  The  changes 
are  : 

1.  Great  thickening  and  induration  of  the  lacerated  lips,  which,  if 
possible  to  roll  into  the  uterine  canal  at  all,  would  cause  traction  upon 
the  sutures,  and  result  in  their  cutting  out;  or,  if  union  should  occur, 
the  induration  and  thickening  might  persist  and  give  increased  trouble. 

2.  Extensive  cystic  degeneration  of  the  Nabothian  follicles.  The 
evil  results  of  rolling  these  cysts  into  the  cervical  canal  have  been 
mentioned. 

3.  Endocervicitis,  with  deep  involvement  of  the  cervical  glands, 
and  a  consequent  profuse  discharge  of  a  ropy,  tenacious,  gelatinous 
secretion.  The  only  satisfactory  treatment  of  this  condition  is  ex- 
cision of  the  diseased  structures.  Their  destruction  by  the  cautery 
or  sharp  curette  is  apt  to  be  follow^ed  by  contraction  and  stenosis  of 
the  cervix  and  is  therefore  objectionable. 

4.  Stenosis   in   the   lower  portion   of   the   cervical    canal    and    os 


688 


TRAUMATISMS. 


externum.  This  condition  may  be  clue  to  too  tight  closure  of  the 
cervix  or  to  cicatricial  contraction  from  curettage,  cauterization,  or 
other  causes. 

Under  the  conditions  named  above,  the  diseased  tissue  should  be 
removed  by  resection  of  the  cervix — Schroeder's  operation}  The 
technique  of  the  operation  is  as  follows  :  The  diseased  tissue  is  removed 
by  incisions  as  indicated  by  the  dotted  lines  in  Figure  309,  the  vagi- 
nal margins  of  the  wound  then  are  stitched,  both  anteriorly  and  poste- 


FlGURE  307. 


Left  lateroprone  position  ;  exposure  by  Sims'  speculum.  The  sutures  tied  and  the  cervix 
united,  as  seen  looking  through  the  speculum  into  the  vagina.  Notice  the  lines  of  union  run- 
ning irom  the  os  over  the  cervix  across  the  uterovaginal  attachment  into  the  reflected  vaginal 
wall.    In  this  case,  as  in  all  others,  a  great  part  of  the  tear  is  in  the  vaginal  walls. 

riorly,  witli  fine  chromicized  catgut,  to  the  margins  of  the  intracervi- 
cal  mucous  membrane.  By  this  means  the  anterior  and  posterior 
lips  of  the  cervix  are  folded  upon  themselves.  Figure  310.  The 
first  stage  of  the  operation  is  now  complete,  and  the  condition  becomes 
that  of  an  uncomplicated  bilateral  laceration.  The  remainder  of  the 
operation  is  the  same  as  that  of  trachelorrhaphy,  already  described. 

1  Emmet  had  for  many  years  before  the  publication  of  Schroeder's  operation  performed  an 
operation  in  principle  like  Schroeder's,  but  differing  in  technique, 


PUERPERAL  LACERATION   OF  THE  CERVIX  UTERL        589 

Before   proceeding    to   excision   of  the    diseased    structures,   it    is 
often  necessary  to  supplement  Schroeder's  operation  by  deep  lateral 

Figure  308. 


Introduction  of  a  suture  with  the  patient  in  the  dorsal  position  and  the  cervix  exposed  bv 
means  of  Simon's  retractor— counter-pressure  by  the  index  finger.  The  illustration  shows  in 
the  lower  left-hand  corner  counter-pressure  by  means  of  the  tenaculum. 


incisions  with  the  scissors.     By  this  means  tlie  anterior  and  posterior 
lips  may  be  separated  widely  far  up  into  the  uterine  canal,  and  the 

36 


590 


TRA  UMA  TISMS. 
Figure  309. 


Shows  a  thickened  diseased  cervix  requiring  resection.    The  dotted  lines  indicate  the 
directions  of  the  incisions. 

diseased   structures    thoroughly    inspected    and    efficiently    removed. 
The  diseased  tissue  is  removed  best  by  seizing  it  in  small  vulsellum 

Figure  310. 


Shows  the  diseased  tissues  excised  and  sutures  in  place,  but  not  yet  tied,  to  unite  the  vaginal 
margin  to  the  cervical  margin  of  the  wound. 


forceps  or  a  tenaculum  and  cutting  it  out  with  two  or  three  strokes  of 
the  scissors.     The  frequent  closure  of  the  lacerated   cervix   without 


PUERPERAL  LACERATION  OF  THE  CERVIX   UTERI        591 

the  removal  of  these  diseased  structures  accounts  for  numerous  fail- 
ures and  disappointments  in  the  operation. 

The  brief  report  of  a  single  case  ^  will  serve  to  illustrate  the  im- 
portance  of  resection.      Trachelorrhaphy   had   been   performed   ten 

Figure  311. 


Anterior  and  posterior  vaginal  margins,  each  turned  into  the  cervical  canal  and  united  by 
means  offlne  catgut  sutures  to  the  intracervical  margins  of  the  wound.  Lateral  surfaces 
denuded  and  sutures  placed  as  in  ordinary  trachelorrhaphy,  but  not  yet  tied. 

years  previously.  From  the  time  of  that  operation  the  patient  had 
suffered  from  pronounced  catalepsy,  with  frequent  paroxysms.  Ex- 
amination showed  an  enormously  thickened  cervix  with  a  pinhole  os. 

Figure  312. 


All  sutures  tied  ;  operation  complete.    The  white  dots  in  the  os  represent  the  protruding 

intrnnprviPfll    Rlit.nrps, 


intracervical  sutures. 

Both  ovaries  were  enlarged  slightly  and  adherent.  lu  order  to  ascer- 
tain the  condition  of  the  interior  of  the  cervix,  very  deep  bilateral 
incisions  were  made  :  the  anterior  and  posterior  lips  were  separated 
more  widely  than  would  be  usual  in  an  extensive  laceration  of  the 
cervix.  Much  pent-up  secretion  which  escaped  showed  that  the  tight 
closure  of  the  os  externum  had  converted  the  whole  endometrium 

1  Dudley.    "  The  Abuse  of  Emmet's  Operation  for  Laceration  of  the  Cervix."  Journal  of  the 
American  Medical  Association,  September  23,  1893. 


592  TRAUMATISMS. 

iuto  a  retention-cyst.  Numerous  cysts  of  the  Nabothian  follicles, 
superficial  and  deep,  large  and  small,  appeared  in  the  intracervical 
mucosa  and  submucosa.  In  excision  of  these  cysts  the  cervical 
mucosa  and  submucosa  were  removed  almost  to  the  internal  os ;  the 
vaginal  and  intracervical  margins  of  the  wound  were  united  with  cat- 
gut sutures,  as  shown  in  Figure  310.  What  remained  of  the  lateral 
incisions  was  closed  then  with  interrupted  silkworm  gut  sutures. 
The  operation,  except  the  very  deep  lateral  incisions,  was  practicaaly 
that  of  Schroeder.  Since  recovery  from  the  operation  the  patient, 
though  naturally  neurotic,  has  reported  herself  free  from  catalepti- 
form  seizures. 

The  After-treatment  of  trachelorrhaphy,  or  Schroeder's  operation, 
consists  of  rest  in  bed  for  about  ten  days,  a  vaginal  douche  of  hot 
sterilized  water  twice  daily,  and  removal  of  the  sutures  through  Sims' 
or  Simon's  speculum  in  about  two  weeks.  If  the  perineum  and 
cervix  are  closed  at  the  same  time,  the  pressure  of  the  speculum 
during  the  removal  of  the  cervical  sutures  does  not,  with  careful 
manipulation,  endanger  the  freshly  united  perineum,  provided  the 
perineal  sutures  are  still  in  place ;  if  they  have  been  removed,  it  is 
necessary  to  delay  removal  of  the  cervical  sutures  until  the  perineal 
union  is  solid — that  is,  for  an  additional  two  or  three  weeks.  It  is 
better,  however,  in  the  double  operation,  as  already  stated,  to  use 
in  the  cervix  absorbable  catgut  sutures,  which  do  not  have  to  be 
removed  at  all. 

Results. — Trachelorrhaphy  in  suitable  cases,  properly  performed 
with  due  regard  to  asepsis,  is  one  of  the  most  satisfactory  operations 
in  gynecology.  Union  by  first  intention  is  the  almost  invariable 
rule.     The  relief  from  symptoms  is  often  very  great. 

Disappointment  in  the  operation,  as  already  stated,  may  result : 

1.  From  neglect  to  treat  the  complicating  endometritis. 

2.  From  the  rolling  in  of  hopelessly  diseased  structures,  which 

ought  to  have  been  excised. 

3.  From  disregarding  such  contraindications  as  pelvic  suppura- 

tion. 

4.  From  closing  the  os  externum  so  tightly  as  to  obstruct  the 

natural  outflow  of  uterine  secretions. 

5.  From  the  unwise  selection  of  cases. 

6.  Above  all,  from  faulty  technique  in  the  operation  itself. 


CHAPTER    XLIII, 

GENITAL   FISTULiE. 

Priority  in  the  Operation  for  Genital  Fistulse. 

Up  to  forty  years  ago,  when  the  operation  for  the  closure  of 
vaginal  fistulse  was  developed  and,  in  practical  form,  given  to  the 
world    by    J.    Marion    Sims,    these    most   distressing    injuries    had 

Figure  313. 


Vesico-uterine  fistula.     Vesico-utcmvat^inal  fistula.     Vesicovaginal  fistula.     Urethrovaginal 
fistula.    Rectovaginal  fistula.    Perineo-anal  fistula.    Anal  fistula. 

been  incurable.  The  invention  of  Sims'  speculum,  which  made  the 
operation  possible,  has  a  significance,  however,  more  far-reaching 
than  the  mere  recognition  of  a  valuable  operation,  for  it  marks  an 
epoch    in    the  history  of  gynecology.     The    operation    furnished  the 

593 


594  TRAUMATISMS. 

initiative  for  the  period  of  great  practical  activity  which  followed.  It 
will  in  no  respect  detract  from  the  credit  which  justly  belongs  to  the 
great  pioneer  if  we  admit  the  fact  that  the  honor  of  perfecting  and 
perpetuating  the  methods  upon  which  his  operation  was  based,  and 
upon  which  modern  gynecology  has  made  its  greatest  development, 
must  be  divided  between  J.  Marion  Sims  and  Thomas  Addis  Emmet. 

Varieties  of  Genital  Fistulse. 

A  fistulous  opening  may  connect  the  interior  of  the  uterus  or 
vagina  with  some  part  of  the  urinary  or  intestinal  tract.  Accord- 
ingly, the  varieties  of  genital  fistulse  are  urinary  fistulse  and  fecal 
fistulse. 

Figure  313  shows  the  more  common  varieties  of  genital  fistulse. 
They  are : 

Vesicovaginal  fistula.  Urethrovaginal  fistula. 

Vesico-uterine  fistula.  Rectovaginal  fistula. 

Vesico-uterovaginal  fistula. 

The  following  other  forms  are  of  rare  occurrence  :  The  ureter 
may  communicate  directly  with  the  vagina,  making  a  ureterovaginal 
fistula.  The  ureter  may  open  into  the  margin  of  a  vesicovaginal 
fistula,  mnJdng  a  uretero-vesicovaginal fidida.  Various  other  rare  forms, 
such  as  uretero-uterine  fistula,  should  be  classed  as  sura^ical  curiosities. 

The  causes  of  genital  fistulse  are  these  : 

Impaction  of  the  presenting  part  during  labor  and  consequent 
pressure-necrosis. 

Direct  traumatism. 

Congenital  causes — that  is,  defective  development. 

Ulcerative  and  other  destructive  processes  from  syphilis,  cancer, 
and  inflammation. 

Burrowing  of  pus  from  abscess. 

VESICOVAGINAL    FISTULA. 

The  definition  of  the  lesion  is  apparent  from  the  name — that  is,  an 
opening  between  the  bladder  and  vagina. 

Etiology  of  Vesicovaginal  Fistula. 

In  the  vast  majority  of  cases  the  lesion  results  from  impaction  of 
the  presenting  part  during  labor  and  consequent  pressure-necrosis  in 
the  vesicovaginal  wall.  Completion  of  the  necrotic  process  and  sepa- 
ration of  the  slough  require  from  five  to  twelve  days  ;  hence,  in  fistula 
from  this  cause  the  essential  symptom,  escape  of  urine  through  the 
vagina,  does  not  occur  until  several  days  after  labor. 

A  fistulous  opening  sometimes  is  made  purposely  by  a  surgical 
operation  for  the  treatment  of  cystitis  or  for  the  removal"  of  stone  in 
the  bladder,  or  it  may  be  the  result  of  accidental  traumatism.  The 
escape  of  urine  will  then  be  immediate.  Congenital  fistula  is  rare, 
and  is  characterized  by  the  involuntary  escape  of  urine  from  the  time 


GENITAL  FISTULA.  595 

of  birth.  The  ulcerative  jirocesses  of  syphilis,  cancer,  and  inflamma- 
tion are  much  more  frequently  the  cause  of  fecal  than  of  urinary 
fistula. 

Symptoms  and  Course  of  Vesicovaginal  Fistula. 

The  constant  symptom,  already  mentioned,  is  the  escape  of  urine 
from  the  bladder  through  the  vagina.  The  fistula  may  vary  from 
the  size  of  a  pinpoint  to  that  of  the  entire  vesicovaginal  wall.  When 
the  opening  is  of  appreciable  size  or  large,  the  flow  of  urine  usually  is 
continuous.  In  very  small  fistulae  the  escape  of  urine  may  be  inter- 
mittent. The  intermission  is  apt  to  occur  when  the  woman  is  lying 
down.  In  rare  cases  of  small  fistula  a  valve-like  formation  may  shut 
oiF  the  flow  of  urine  except  when  the  woman  assumes  certain  positions 
favorable  to  its  escape. 

A  Cause  of  Cystitis. — In  the  majority  of  cases  there  is  more  or 
less  residual  urine  in  the  bladder.  This  is  a  good  culture-medium 
for  bacteria  which  now  find  ready  access  from  the  vagina  to  the 
bladder  ;  hence  cystitis  is  a  usual  complication.  From  this  cause  the 
urine  becomes  alkaline,  ammoniacal,  and  excessively  irritating.  The 
vagina,  external  genitals,  thighs,  and  buttocks,  over  which  it  flows, 
become  excoriated,  oedematous,  and  ulcerated.  A  gritty,  offensive 
phosphatic  deposit  may  form  and  deeply  incrust  not  only  these  sur- 
faces, but  also  the  raw  margins  of  the  fistula  and  the  bladder  mucous 
membrane.  This  deposit  is  specially  apt  to  accumulate  and  form 
incrustations  on  ulcerated  and  otherwise  exposed  surfaces.  It  may 
fill  the  vagina  and  even  extend  over  the  ulcerated  labia.  The  inside 
of  the  bladder,  perchance  deeply  ulcerated,  granulating,  incrusted, 
bleeding,  and  excessively  painful,  may,  in  rare  cases,  if  the  fistula  be 
large,  become  inverted  and  protrude  in  a  semi-strangulated  condition 
between  the  labia  majora.  The  patient,  within  a  few  weeks  after 
labor,  will  then,  unless  great  care  is  exercised,  become  an  object  of 
loathing  or  pity. 

Diagnosis  of  Vesicovaginal  Fistula. 

The  opening,  if  sufficiently  large,  may  be  felt  by  the  finger  in  the 
vagina.  The  fistula,  thus  having  been  located,  the  finger  may  be  used 
as  a  guide  for  the  passage  of  a  sound  through  the  urethra  into  the 
bladder,  and  thence  through  the  fistulous  opening  into  the  vagina. 

When  the  fistula  is  very  small,  it  is  sometimes  difficult  or  im- 
possible to  see  it  even  after  careful  search  with  the  speculum.  In 
such  a  case,  the  speculum  being  in  place,  the  bladder  should  be  in- 
jected through  the  urethra  with  sterilized  colored  water.  The  point 
at  which  this  fluid  escapes  into  the  vagina  will  locate  the  fistula. 

Prognosis  of  Vesicovaginal  Fistula. 

The  prognosis  depends  upon  the  extent  of  the  injury,  the  amount 
of  cicatricial  tissue,  and  the  difficulty  of  approximating  the  margins 
of  the  fistula.     In  exceptional  cases  of  small  opening,  in  which  the 


596  TEA  UMA  TISMS. 

margins  lie  in  easy  and  close  apposition,  they  may,  if  kept  clean,  soon 
unite  without  operative  interference.  The  vast  majority  of  fistulae, 
however,  unless  united  by  sutare,  are  permanent. 

Prophylactic  Treatment  of  Vesicovaginal  Fistulse. 

The  statistics  of  Emmet,  covering  a  long  series  of  cases  of  vesico- 
vaginal fistula,  show  that' the  average  duration  of  labor  from  the  time 
of  rupture  of  the  membranes  to  the  birth  of  the  child  was  between  two 
and  three  days.  Statistics  further  prove  that  impaction  and  conse- 
quent continued  pressure  of  the  presenting  part  upon  the  vesicovaginal 
septum,  even  for  a  few  hours,  are  very  liable  to  result  in  cutting  off  the 
circulation  and  in  consequent  death  and  sloughing  of  the  compressed 
tissue.  If,  therefore,  in  any  case  imjmdion  becomes  apparent  by  the 
failure  of  the  j'^resenting  part  to  advance  during  the  pains  and  to  recede 
in  the  interval  between  the  pains,  delivery  should  be  hastened  and  termi- 
nated without  unnecessary  delay.  The  possible  danger  of  a  forceps 
operation  in  such  a  case,  even  by  the  inexperienced  hand,  when  com- 
pared with  the  danger  of  fistula,  would  be  insignificant. 

Emmet's  records  show  that  in  nearly  all  his  cases  parturition  had 
taken  place  either  without  attendance  or  under  the  care  of  ignorant 
midwives.  In  some  cases  labor  had  terminated  finally  by  the  unaided 
efiForts  of  nature,  and  in  others  by  the  use  of  the  forceps.  In  the 
latter  class  of  cases  delivery  is  accomplished  usually  by  a  consultant, 
who  is  not  called  until  after  prolonged,  continuous  pressure  has  de- 
stroyed the  vitality  of  at  least  a  part  of  the  vaginal  wall.  Sometimes 
the  fistula  is  attributed  wrongly  to  the  forceps  or  other  instruments, 
instead  of  the  real  cause — prolonged  pressure — a  cause  which  earlier 
interference  would  have  prevented.  As  Thomas  wisely  remarks,  the 
truth  on  this  point  should  be  set  forth  clearly  to  the  friends  of  the 
patient  before  forceps  are  applied,  "  for  unless  it  be  so,  an  incom- 
petent person  may  shield  himself  from  merited  blame  by  casting 
censure  upon  a  consulting  physician,  by  whose  efforts  the  lives  of  both 
mother  and  child  may  have  been  saved ;  and  thus  a  skilful  operator 
may  suffer  unjustly  in  a  suit  for  malpractice." 

Emmet's  statistics  show  that  in  a  large  proportion  of  cases  the 
bladder  was  not  emptied  during  the  progress  of  labor.  This  neglect 
would  cause  large  accumulation  of  retained  urine  and  great  distention 
of  the  bladder.  The  result  would  be  paralysis  of  the  bladder  and 
cystitis.  Moreover,  the  impaction  would  be  increased  by  the  pressure 
urine  exerted  on  the  bladder  side  of  the  vesicovaginal  septum,  and 
this  pressure  would  be  an  additional  cause  of  necrosis.  Catheterization, 
therefore,  as  a  prophylactic  measure  is  an  urgent  necessity. 

After  delivery  in  a  case  of  continuous  and  prolonged  impaction, 
decided  antiseptic  measures  are  indicated  to  prevent  or  limit  the 
threatened  necrosis.     They  are  : 

1.  A  vaginal  douche  of  0.5  per  cent,  lysol,  or  some  other  appro- 
priate antiseptic,  every  eight  hours. 

2.  Daily  washing  out  of  the  bladder  with  a  saturated  solution  of 
boric  acid. 


GENITAL  FISTULM.  597 

3.  Sufficiently  frequent  catheterization  to  prevent  great  accumula- 
tions of  urine  and  consequent  bladder  distention. 

Surgical  Treatment  of  Vesicovaginal  Fistula. 

The  surgical  treatment  includes  the  preparatory  treatment,  the 
operation,  and  the  after-treatment. 

Preparatory  Treatment. — If  the  parts  are  brought  into  a  condi- 
tion favorable  for  union,  the  operation  for  the  cure  of  vesicovaginal 
fistula,  even  with  ordinary  skill,  is  one  of  the  most  satisfactory  in  the 
whole  field  of  surgery.  On  the  other  hand,  the  most  skilful  opera- 
tion, with  faulty  preparation,  is  almost  certain  to  fail. 

Phosphatic  Deposits. — The  margins  of  the  fistula  cannot  be  brought 
into  a  healthy  condition  and  made  fit  for  union  until  the  phosphatic 
deposit  already  mentioned  has  been  removed,  and  the  further  forma- 
tion of  it  prevented.  To  this  end,  the  urine  should  be  rendered  acid  ; 
otherwise  the  deposit  will  accumulate  on  the  sutures  and  in  the  lines 
of  union,  and  cause  the  operation  to  fail.  It  does  not,  however, 
develop  in  acid  urine.  Emmet's  mixture  of  benzoic  acid,  two 
drachms ;  borax,  three  drachms ;  and  cinnamon  water,  twelve  ounces, 
gives  uniformly  good  results.  A  tablespoonful,  further  diluted, 
should  be  taken  four  times  a  day  until  the  urine  becomes  mildly  acid. 
The  dose  then  should  be  regulated  to  maintain  normal  acidity  and  to 
avoid  deranging  the  digestion.  The  acid  sodium  phosphate  in  30  grain 
dose,  well  diluted,  is  most  useful  to  render  the  urine  acid.  In  order 
to  dilute  the  urine  and  render  it  less  irritating,  pure  water  should  be 
given  quite  freely.  If  the  urine  is  kept  slightly  acid  and  well  diluted, 
the  phosphatic  deposit  once  removed  will  not  return. 

The  removal  of  the  deposit  is  accomplished  best  by  means  of  a 
dressing-forceps,  or  it  may  be  brushed  off  with  a  wad  of  cotton  in  the 
grasp  of  the  forceps,  after  which  the  raw  surfaces  should  be  treated  by 
means  of  a  solution  of  silver  nitrate,  ten  grains  or  more  to  the  ounce, 
on  an  applicator  wound  with  absorbent  cotton.  Sometimes  the  deposit 
adheres  very  firmly,  as  if  it  were  interlaced  with  the  adjacent  and 
underlying  tissue,  so  that  immediate  removal  would  be  too  difficult 
or  painful.  Emmet  then  applies  a  stronger  solution  or  even  the  solid 
stick  of  silver  nitrate  to  the  deposit  itself.  This  may  be  repeated 
every  few  days  until  the  deposit  is  detached. 

The  hot  vaginal  douche  described  in  Chapter  IV.  is  of  the  utmost 
value  in  the  preparatory  treatment.  It  should  be  given  freely  several 
times  a  day,  and  large  quantities  of  hot  water  should  be  used.  This 
part  of  the  treatment,  as  Emmet  declares,  is  indispensable.  The  sitz- 
bath  also  is  most  useful  and  grateful  to  the  patient.  The  douche  may 
be  given  to  advantage  and  with  increased  comfort  while  the  patient 
is  in  the  sitz-bath.  This  treatment,  merely  insuring  perfect  cleanli- 
ness, has  resulted  in  some  cases,  even  of  large  fistula,  in  spontaneous 
closure.  They  were  cases,  however,  in  Mhich  there  had  not  been 
great  loss  of  tissue,  and  in  which  the  edges  of  the  fistula  were  in 
apposition. 

The  excoriated  or  eroded  surfaces  about  the  nates  or  thighs  are 


598  TBA  UMA  TISMS. 

treated  best  by  frequent  bathing,  followed  by  applications  of  ben- 
zoated  zinc  oxide  ointment.  Napkins  like  menstrual  napkins  should 
be  worn  over  the  vulva  to  absorb  the  urine,  and  should  be  changed 
frequently ;  otherwise  the  urine  which  they  hold  will  decompose  and 
become  excessively  irritating  to  the  skin.  Points  of  ulceration  may 
be  touched  with  solid  silver  nitrate. 

Cystitis,  if  present,  is  a  clear  contraindication  to  immediate  closure 
of  the  fistula.  The  copious  hot-water  vesicovaginal  douche,  fre- 
quent and  prolonged,  is  the  best  means  of  treating  this  complica- 
tion. It  is  given  as  an  ordinary  vaginal  douche,  except  that  the  hot 
water,  instead  of  being  thrown  in  by  the  douche  point  through  the 
vulva,  is  introduced  through  the  urethra.  For  this  purpose  a  glass 
urethral  catheter  or  canula  small  enough  to  enter  the  urethra  is  used 
in  place  of  the  vaginal  douche  point.  The  hot  water  by  this  means 
is  applied  first  freely  to  the  bladder,  and  then  through  the  fistula  to 
the  vagina  and  vulva.  Cystitis  in  these  cases,  as  already  explained, 
is  sometimes  the  result  of  residual  urine.  It  may  therefore  be  neces- 
sary, especially  in  a  very  small  fistula,  to  secure  adequate  drainage  of 
the  bladder  by  an  incision  in  the  vesicovaginal  wall.  If  the  fistula  is 
situated  in  or  near  the  median  line  of  the  vesicovaginal  septum,  the 
incision  should  be  so  made  as  to  enlarge  it,  otherwise  an  independent 
opening  should  be  made.  See  Treatment  of  Cystitis  by  Means  of 
Artificial  Vesicovaginal  Fistula,  in  Chapter  XXIV.  Old  inflam- 
mation of  the  kidney  or  ureter  may  be  present,  and  if  in  an  advanced 
stage  might  contraindicate  the  operation  ;  hence  the  importance  of  the 
rule  to  examine  the  urine  in  every  case.  The  urine  may  be  collected 
for  examination  by  keeping  the  woman  on  a  bedpan  until  a  sufficient 
quantity  has  accumulated. 

Stone  in  the  Bladder,  free  or  encysted,  may  in  rare  cases  have  ante- 
dated and  even  been  a  cause  of  fistula — that  is,  the  vesicovaginal 
septum  during  labor  may  have  been  compressed  between  the  stone 
and  the  child's  head.  Usually,  however,  the  calculus  is  deposited 
from  the  residual  urine  already  mentioned  among  the  frequent  results 
of  fistula.  The  necessity  for  the  removal  of  such  a  stone  before  closing 
the  fistula  is  apparent. 

Direction  and  Manner  of  Closure. — The  urine  being  normal,  the 
vagina  and  bladder  healthy,  and  the  structures  surrounding  the  fistula 
fit  for  union,  the  next  step  will  be  to  decide  upon  the  best  direction 
and  manner  of  closure.  In  order  to  preserve  the  length  of  the 
vagina,  it  is  desirable,  if  possible,  to  bring  the  parts  together  from  side 
to  side,  so  as  to  make  a  line  of  union  as  nearly  as  possible  in  the  long 
axis  of  the  vagina.  A  line  of  union  transversely  across  the  vagina 
would  shorten  its  anterior  wall  and  would  draw  down  the  uterus  and 
fix  it  in  permanent  displacement. 

Unfortunately,  in  many  cases  of  extensive  sloughing  the  margins 
of  the  fistula  cannot  be  approximated  from  side  to  side.  They  may 
even^  be  so  held  apart  by  cicatricial  bands  that  they  cannot  be  ap- 
proximated at  all,  for  there  may  not  be  sufficient  tissue  left  to  fill  the 
gap.  In  order  to  decide  upon  the  best  mode  and  direction  of  closure, 
the  fistula  should  be  exposed  by  Sims'  speculum,  and  its  margins  at 


GENITAL  FISTULA. 


599 


different  points  seized  on  opposite  sides  and  drawn  together  with  a 
tenaculum  in  each  hand.  In  this  way  one  may  judge  of  the  amount 
of  force  required  to  approximate  the  edges,  and  of  the  direction  in 
which  they  will  come  together  with  the  least  traction. 

It  is  an  urgent  rule  never  to  introduce  sutures  unless  the  surfaces  to 
be  united  can  be  held  in  contact  ivithout  traction  ;  even  a  little  traction  on 
the  sutures  will  cause  them  invariably  to  cut  out  and  the  operation  to  fail. 

If  the  restraining  bands  are  so  light  and  superficial  that  moderate 
traction   with    tenacula  suffices  to  approximate  the    margins  of   the 

Figure  314. 


Vesicovaginal  fistula  exposed  by  Sims'  speculum.    Approximation  of  the  margins  attempted 
by  means  of  tenacula.     Left  lateroprone  position. i 

fistula,  the  bands  may  be  divided  with  scissors  until  the  margins  readily 
fall  together.  The  surfaces  then  may  be  denuded  immediately  and 
the  sutures  introduced. 

If  the  sloughing  has  been  very  extensive,  one  or  more  preliminary 
operations  may  be  necessary.  Emmet  places  the  patient  on  her  back, 
introduces  two  fingers  of  the  left  hand  into  the  rectum,  and  the  thumb 
of  the  same  hand  into  the  vagina.  The  interior  of  the  vagina  thereby 
is  rolled  out  and   exposed  without  a  speculum.      The  right  index- 

'  Emmet.    Principles  and  Practice  of  Gynecology. 


600  TRAUMATISMS. 

finger  in  the  vagina  now  detects  the  points  of  greatest  cicatricial  ten- 
sion. Point  after  point  is  snipped  with  the  blunt  scissors  in  such  a 
way  as  to  render  the  margins  of  the  fistula  more  readily  approximated. 
If  the  cervix  uteri  has  sloughed,  the  relations  of  the  remaining  por- 
tion of  the  uterus  to  the  upper  part  of  the  vagina,  even  by  rectal 
touch,  may  be  difficult  to  make  out.  There  is  then  great  danger  of 
wounding  a  misplaced  ureter  or  of  entering  the  peritoneum.  This 
danger  is  lessened  by  the  careful  use  of  the  sound  held  by  the  hand 
of  an  assistant  in  the  bladder. 

The  restraining  bands  having  been  divided  as  freely  as  may  be 
deemed  prudent,  Emmet  directs  that  a  Sims  glass  or  hard-rubber 
vaginal  plug  be  introduced  and  held  in  place  by  a  T-bandage.  It 
should  be  sufficiently  long  and  wide  to  keep  the  vagina  well  stretched 

FlQUEE  315. 


Sims'  glass  vaginal  plug. 

both  longitudinally  and  laterally,  and  to  control  hemorrhage  by  press- 
ure, but  not  so  large  as  to  cause  pressure-necrosis  and  sloughing. 
Under  this  pressure,  absorption  of  cicatricial  tissue  is  rapid.  The 
continued  stretching  of  the  vagina  also  increases  its  calibre  and 
renders  approximation  of  the  margins  of  the  fistula  less  difficult. 
The  dilator  may  have  to  be  retained  for  several  weeks  until  the  inci- 
sions have  healed  over  it ;  in  the  meantime  it  may  be  removed  daily 
for  cleansing  douches.  The  patient  should  be  kept  in  bed  for  a  week 
or  two  after  this  preliminary  operation,  and  the  urine  should,  if  neces- 
sary, be  drawn  with  a  catheter.  After  healing  has  taken  place,  the 
operation,  if  necessary,  may  be  repeated  ;  or,  if  the  margins  of  the 
fistula  can  be  brought  together  without  tension,  the  sutures  for  clos- 
ure may  be  introduced. 

In  place  of  the  incisions  and  glass  dilator  just  described,  the  re- 


GENITAL  FISTULJE. 


601 


straining  cicatricial  bands  may  be  divided  deeply  and  freely  and  the 
wounds  closed  at  right  angles  to  the  lines  of  incision.  The  operation 
is  illustrated  in  Figures  316,  317,  and  318.     This  preliminary  plastic 


Figure  316. 


1,  2,  and  3,  4,  represent  the  restrainingcicatrical  bands  on  each  side  of  the  fistula ;  ah  and  ef 

show  the  lines  of  incision. 

work  may,  according  to  indication,  be  done  at  the  time  of  closing  the 
fistula  or  as  a  separate  operation. 

The  preparatory  treatment  outlined  above  may  be  difficult,  long 


Figure  Sll 


The  wounds  made  by  incisions  ah  and  ef  are  drawn  widely  apart  by  tenacula  so  as  to 
give  the  wound  on  either  side  the  direction  of  cd  and  gh.  Sutures  are  in  place  on  right 
side 

continued,  and  most  trying  to  patient  and  surgeon.  Fortunately, 
there  are  many  cases  in  which  it  is  not  required.  When  it  is  required, 
the  most  skilful  operation  will  fail  without  it. 

Figure  318. 


Incised  wounds  on  both  sides  of  the  fistula  closed  at  right  angles  to  lines  of  incision.  The 
edges  of  the  fistula  now  readily  fall  into  apposition.  Sutures  foi  closure  of  fistula  in  place,  and 
two  of  them  tied. 


The  Operation  for  Closing  the  Fistula. — This  involves  a  con- 
sideration of  the  following  topics  : 

1.  General  preparatory  treatment. 

2.  Choice  of  speculum  and  method  of  operation. 


602 


TRAUMATISMS. 


3.  Choice  of  direction  for  closure  of  the  fistula. 

4.  Denudation. 

5.  Introduction  of  sutures. 

6.  After-treatment. 

1.  The  General  Preparatory  Treatment  and  arrangements  for  plastic 

operations  described  in  Chapter  II.  are  applicable  and  adequate  for 

this  operation. 

Figure  319. 


The  use  of  the  uterine  tenaculum  and  Emmet's  scissors  in  denudation.    Left  lateroprone 
position ;  exposure  by  Sims'  speculum. 

2.  Choice  of  Speculum  and  Method  of  Operation. — The  author's 
choice  between  the  method  of  Simon,  with  the  patient  in  the  dorsal 
position,  the  parts  being  exposed  by  numerous  vaginal  retractors,  and 
the  method  of  Sims,  with  the  left  lateroprone  position  and  Sims' 
speculum,  is  based  upon  an  extensive  experience  with  both  methods. 
The  Simon  method  is  serviceable  and  adequate  for  the  ordinary  case, 
but  not  always  for  difficult  cases.  This  is  especially  true  when  the 
fistula  is  near  the  vaginal  outlet  behind  the  ramus  of  the  pubes.  In 
fat    subjects,  moreover,  the  Sims  position  and  speculum  are  almost 


GENITAL  FlSTULvE. 


603 


indispensable.  Decided  preference  therefore  is  given  to  the  n.ethod 
of  Sims  as  taught  and  practised  by  Emmet.  The  position  of  the 
patient  and  the  use  of  the  speculum  are  described  in  Chapter  III, 

3.  Direction  of  the  Line  of  Union. — In  order  to  decide  upon  tlie 
exact  direction  for  closure,  the  edges  of  the  fistula  are  approximated 
in  diiferent  ways  with  tenacula,  until  that  direction  is  found  and 
adopted  which  permits  the  margins  of  the  fistula  to  be  apjiroximated 
with  the  least  traction.     For  reasons  already  given,   it   is   always 

Figure  320. 


The  proper  area  of  denudation.    The  denuded  surfaces  correspond  to  the  deck  and  the  fistula 
to  the  manhole  of  a  canoe.     Left  lateroprone  position  ;  exposure  by  Sims'  speculum. 

desirable  to  make  the  line  of  union,  if  possible,  in  the  direction  of  the 
long  axis  of  the  vagina. 

4.  Denudation.— The  edges  of  the  fistula  are  denuded  by  means  of 
the  tenaculum  and  scissors,  as  shown  in  Figure  319. 

The  skilful  hand  will  denude  superficially  or  deeply,  as  may  be 
required.  The  denuded  surfaces  should  be  made  clean  and  smooth, 
and  the  bleeding  should  be  slight.  For  denudation  the  uterine 
tenaculum  and  scissors  are  far  superior  to  the  tissue  forceps  and  the 
scalpel. 


604 


TRAUMATISMS. 


The  margins  of  the  fistula  are  seized  with  the  tenaculum,  at  the 
point  nearest  the  operator,  and  a  strip  is  cut  away  all  around  the 


Figure  321. 


a  this  cut  IS  suggested  by  a  similar  one  in  a  standard  work,  and  shows  how  the  denuda- 
tion should  not  be  made.  The  scissors  are  preferable  to  the  knife  and  the  tenaculum  to  the 
torceps;  b,  c,  when  the  fistula  is  made  in  this  way  there  is  apt  to  be  failure  of  uuion  at  the 
puckered  ends  of  the  united  wound. 

opening.  It  is  highly  important  that  broad  surfaces  be  secured  for 
approximation;  hence  it  may  be  necessary  to  remove  one  or  more 
additional    strips    around    the  opening.       If  sloughing   has   left  the 


GENITAL  FISTULA. 


605 


edges  about  the  fistula  quite  thin,  the  denuded  surfaces  should  be 
correspondingly  broader.     The  two  points    upon  which    to  lay  the 


Figure  322. 


A  CORRECT    METHOD  OF  OPERATING. 

b    -A 

a 


a,  correct  method  of  denudation  wiih  tenaculum  and  scissors  :  b,  correct  form  of  denuded 
surface.  First  suture  being  introduced  for  closure  of  fistula  in  direction  of  long  axis  of  vagina  ; 
c,  same  as  b,  with  closure  of  fistula  completed ;  d,  first  suture  being  introduced  for  closure  of 
fistula  in  transverse  axis  of  vagina  ;  e,  same  as  d,  with  closure  of  fistula  completed. 

greatest   stress    are,    first,    adequate    preparatory  treatment ;    second, 
broad   surfaces  for  union.     The    fistula  may  be   so  small  as  to  be 
37 


606  TRAUMATISMS. 

inaccessible  for  denudation,  and  therefore  may  have  to  be  enlarged 
by  incision  in  order  that  its  margins  may  be  freshened  and  united. 

Some  operators  instead  of  denuding,  split  the  edges  of  the  fistula. 
This  method,  though  not  usual,  is  yet  highly  advantageous  when  the 
margins  are  thin,  or  when  it  is  specially  desirable  to  economize  tissue. 
See  Figures  323  and  324.  The  bladder  mucosa,  if  cut,  is  prone  to 
bleed  freely ;  hence  denudation  should  ordinarily  extend  to,  but  not 
into  it.  Hemorrhage  from  the  cut  bladder  mucosa,  even  in  the  care- 
ful hands  of  Emmet,  has  twice  been  so  free  as  to  distend  the  bladder 
with  blood  and  endanger  life.     In  both  cases  the  sutures  were  re- 

FiGUEE  323. 

-V >>  ^  ,- V 

B '         ' B- 

Ordinary  denudation :  V,  V,  vaginal  surface ;  B,  B,  vesical  surface ;  C  and  D,  lines  of  denudation. 

moved  and  the  bleeding  points  secured.  When  the  denuded  strip 
includes  the  bladder  mucous  membrane,  the  cut  margin  may  retract 
into  the  bladder  and  make  the  bleeding  points  quite  inaccessible. 
Complete  ansesthesia,  a  strong  light,  good  position,  and  the  skilful 
use  of  the  speculum  and  uterine  tenacula  may  then  be  necessary  to 
evert  and  expose  bleeding  surfaces  and  control  hemorrhage. 

Emmet  properly  condemns  the  practice  of  simply  denuding  a  strip 
of  uniform  width  around  on  the  vaginal  side  of  the  fistula.  He 
insists  that  the  margins  be  denuded  to  the  vesical  mucosa.  The 
denudation  at  the  angles  of  the  fistula  should,  however,  be  extended 
some  distance  over  the  vaginal  surface,  as  shown  in  Figure   320. 


Figure  324. 

V <Pc      ^ 


^/ 

B  S^  /y — B- 

Flap-Splitting  on  both  sides  seldom  required :  V.  V,  vaginal  surface ;  B,  B,  vesical  surface ;  C.  C, 
and  D,  D,  inner  surfaces  of  split  edges  to  be  coapted. 

Otherwise,  there  will  be  a  double  fold  or  pucker  at  each  angle.  One 
may  illustrate  this  by  picking  up  together  two  small  folds  of  a  napkin, 
and  observing  that  they  extend  a  considerable  distance  before  they 
can  be  smoothed  down  to  the  common  surface.  The  same  is  true  of 
the  vaginal  folds  at  the  two  ends  of  an  improperly  denuded  fistula, 
and  the  denudation  should  therefore  be  so  extended  that  the  folds  are 
lost  on  the  level  of  the  vagina.  Unless  this  precaution  is  observed, 
union  is  apt  to  be  imperfect,  or  may  fail  altogether  at  the  ends  of  the 
line  of  union. 

5,  Application  of  Sutures. — Formerly  the  metallic  suture,  usually 


GENITAL  FISTULA. 


607 


silver,  was  almost  exclusively  used.  Now,  with  aseptic  methods, 
any  suture  is  adequate.  The  writer  prefers  silkworm  gut  tied  on 
the  surface  with  an  ordinary  hard  knot.  The  numerous  devices  for 
fastening  the  sutures  by  means  of  short  metallic  plates,  quills,  split 
shot,  and  other  means  are  useless,  harmful,  or  unnecessary. 

Emmet's  or  Sims'  needle  is  adapted  best  for  ordinary  use  ;  it  is 
short  and  straight,  except  near  the  point,  where  it  is  curved  slightly. 
Occasionally  a  full-curved  needle  may  be  of  service.  The  Emmet 
needle  is  shown  in  Figure  325. 


FtCtUee  325. 


Closing  of  a  vesicovaginal  fistula  :  introduction  of  a  suture.     Left  lateroprone  position ; 
exposure  by  Sims'  soeculum. 

A  needle-forceps  without  locking  handles  is  recommended  because 
it  will  enable  a  dexterous  operator  constantly  to  vary  the  direction  of 
the  needle  during  introduction. 

Tlie  suture  should  be  attached  to  the  needle  in  the  ordinary  way, 
as  a  thread  is  attached  to  a  common  sewing-needle.  The  needle  is 
grasped  by  the  forceps  and  entered  about  one-eighth  of  an  inch  from 
the  margin  of  the  fistula  on  the  vaginal  side ;  it  transfixes  the  vesico- 
vaginal wall  and  emerges  on  the  bladder  side,  so  as  barely  to  include 


608 


TRAUMATISMS. 


the  vesical  margin  ;  it  then  is  passed  through  the  wall  on  the  opposite 
side  in  the  inverse  order,  and  brought  out  one-eighth  inch  from  the 
margin  of  the  vaginal  mucosa  on  that  side.  The  sutures  should  be 
placed  about  one-sixth  of  an  inch  apart.  If  silver  sutures  are  used, 
they  all  should  be  passed  first  and  then  secured  by  twisting.  In  using 
silkworm  gut,  one  usually  should  tie  each  suture  as  it  is  passed.  Let 
the  sutures  be  tied  just  tightly  enough  to  hold  the  parts  together. 
If  tied  too  tightly,  they  strangulate  the  tissues,  cut  out,  and  fail  to 
give  union. 

A  clot  of  blood,  if  left  in  the  bladder  after  closure,  may  cause 
great  vesical  tenesmus  and  possibly  imperil  the  result.  It  is  well, 
therefore,  before  tying  the  final  sutures  to  throw  a  quantity  of  steril- 
ized water  through  the  urethra  into  the  bladder.  This  water  will  pass 
through  the  fistula  into  the  vagina  and  wash  out  anything  remaining 
in  the  bladder. 

6.  After-treatment. — The  patient  is  placed  in  bed  on  the  back,  with 
a  roll  under  the  knees  for  support.  A  self-retaining  Sims'  sigmoid 
catheter  is  placed  in  the  urethra ;  it  should  be  made  of  block-tin  or  of 
glass,  bent  by  the  flame  of  a  spirit  lamp.  The  curves  should  be 
adjusted  to  the  individual  case.     The  urine  passes  through  the  catheter 

Figure  326. 


Sims'  sigmoid  catheter. 

and  is  collected  in  a  urinal  placed  between  the  thighs.  The  catheter 
is  apt  to  become  clogged  with  mucus  or  blood-clots,  and,  therefore, 
should  be  removed  and  cleaned  every  few  liours.  A  second  catheter  is 
desirable,  in  order  that  one  may  always  be  introduced  as  soon  as  the 
other  is  removed.  In  case  of  a  small  fistula  we  may  dispense  some- 
times with  the  self-retaining  catheter  altogether  and  permit  the  patient 
to  pass  the  urine  in  the  natural  way.  Both  patient  and  nurse  should 
be  cautioned  to  see  that  the  flow  of  urine  is  not  interrupted.  The 
catheter  should  remain  about  fourteen  days.  The  sutures,  unless 
removed  earlier  on  account  of  suppuration  or  failure  of  union,  may 
remain  two  or  three  weeks.  The  woman  should  be  kept  in  bed  a 
week  longer,  and  during  this  time  should  be  catheterized  at  frequent 
intervals. 

During  convalescence  the  urine  should  be  kept  normally  acid, 
otherwise  phosphatic  deposits  may  form  in  the  line  of  union  and  on 
the  sutures  and  prevent  or  destroy  union.  The  benzoic  acid  mixture 
or  the  acid  sodium  phosphate,  already  mentioned,  should  therefore  be 
continued.  The  long  retention  of  the  catheter  and  the  continued 
dorsal  position  may  give  rise  to  great  discomfort ;  hence  the  necessity 
in  many  cases  of  using  more  or  less  morphine,  opium,  or  other  ano- 


GENITAL  FISTULA 


609 


dyne.  A  cathartic  should  be  given  on  the  third  day,  and  thereafter 
the  bowels  kept  regular  by  moderate  catharsis  and  euemata.  After 
the  final  removal  of  the  catheter  there  may  be  retention  of  urine,  and 
it  may  be  necessary,  therefore,  in  order  to  prevent  distention  of  the 
bladder,  to  draw  the  urine  every  few  hours.  In  old  cases  the  bladder, 
either  from  disuse  or  from  cystitis,  may  be  much  contracted,  and 
therefore  liable  to  distention  from  a  small  cjuantity  of  urine.  The 
functional  powers  of  the  bladder  and  urethra  progressivelv  improve  as 
the  bladder  gradually  becomes  accustomed  to  the  retention  of  con- 

FiGURE  327. 


Fistula  involving  loss  of  entire  vesicovaginal  septum  as  seen  through  the  speculum. 


sideraljle  quantities  of  urine,  so  that  a  bladder  for  many  years  con- 
tracted by  vesicovaginal  fistula  may  regain  its  full  capacity  in  a  short 
time  after  closure  of  the  opening. 

Atypical  Operations. — The"  ingenuity  and  skill  of  the  operator 
will  enable  him  to  modifv  the  operation  according  to  the  rec^uirements 
of  an  atypical  case.  An  operation  may  be  only  partially  successful, 
and  may  have  to  be  repeated  again  and  again  until  the  closure  is  com- 
plete, or  it  may  be  necessary  to  close  the  opening  only  in  part  at  each 
one  of  several  operations. 

Loss  of  the  Entire  Vesicovaginal  Septum  is  associated  usually  with 


610 


TBA  UMA  TISMS. 


more  or  less  destruction  of  cervical  tissue  and  cicatricial  development 
in  the  posterior  vaginal  fornix.  The  usual  operation  in  such  a  case  is 
to  close  by  a  transverse  line  of  union — that  is,  to  stitch  the  anterior 
lip  of  the  cervix  uteri  to  the  neck  of  the  bladder.  In  some  cases  the 
cervix  is  immovable  and  cannot  be  drawn  down  to  the  neck  of  the 
bladder  until  the  post-cervical  cicatrices  have  been  divided  freely  by  a 
deep  transverse  incision  back  of  the  cervix.  In  order  to  gain  the 
required  reach,  it  may  be  permissible  to  split  the  cervix  bilaterally. 
Figure  328  shows  the  fistula  closed  by  union  of  the  cervix  uteri  to  the 
neck  of  the  bladder. 

Figure  328. 


Anterior  wall  of  cervix  uteri  united  to  the  neck  of  the  bladder. 

but  not  tied. 


One  suture  in  place, 


So  much  of  the  anterior  lip  may  have  sloughed  away  that  it  cannot 
be  drawn  down  to  the  neck  of  the  bladder.  In  such  a  case  some 
operators  turn  the  cervix  uteri  into  the  bladder  by  union  of  the  posterior 
lip  of  the  cervix  to  the  neck  of  the  bladder.  This  would  establish  a 
communication  between  the  interior  of  the  uterus  and  the  bladder. 
Figure  329.  A  great  risk  from  this  operation  is  in  the  possibility  that 
infection  may  pass  from  the  endometrium  to  all  the  urinary  organs  or 
from  the  bladder  to  the  uterus.  Fallopian  tubes,  and  even  to  the 
peritoneum.  The  chief  danger,  however,  is  that  the  operation  may 
form  a  pouch  in  which  urine  will  stagnate,  with  resultant  phosphatic 
deposit  and  incurable  cystitis,  only  to  be  relieved  by  reopening  the 
bladder  and  giving  it  drainage.     See  Artificial  Vesicovaginal  Fistula 


GENITAL  FISTULA. 


611 


for  Cystitis.  If  the  fistula  be  closed,  so  as  to  avoid  the  formation  of 
such  a  pouch,  cystotomy  may  be  unnecessary;  it  is,  unfortunately,  too 
often  impossible  to  avoid. 

Kolpokleisis,  or  closure  of  the  vagina,  is  an  operation  designed  to 
secure  retention  of  urine  in  cases  of  otherwise  inoperable  vesicovag- 
inal fistula.  It  is  performed  by  denuding  a  wide  strip  all  around  the 
vaginal  outlet  just  within  the  vulva  and  uniting  the  denuded  surfaces 
upon  themselves  by  means  of  interrupted  sutures.  The  effect  is  to 
make  one  cavity  of  the  bladder  and  vagina.  This  cavity  receives 
the  urine,  menstrual  blood,  and  uterine  secretions.  The  operation 
always  leads  to  inflammation  more  distressing  than  the  condition  for 
the  relief  of  which  it  has  been  invoked.     Emmet,  in  the  strongest 

Ftguke  329. 


Uterus  turned  into  bladder  to  secure  retention  of  urine.  Posterior  lip  of  cervix  united  to  neck 
of  bladder.    Anterior  lip  of  cervix  sloughed  away.    Uterus  retroverted. 

terms,  condemns  the  operation  and  urges  that  it  never  be  done  in 
any  case.  He  advises  that  the  parts  be  made  to  heal  with  the  open- 
ing unclosed,  and  that  the  patient  be  kept  as  comfortable  without 
an  operation  as  cleanliness  and  care  can  make  her.  The  stagnant 
urine  constantly  present  in  the  vaginal  pouch  firmed  by  the  opera- 
tion always  produces  distressing — not  to  say  dangerous — disease  of 
the  urinary  organs.  In  this  connection  the  writer  offers  from  his 
practice  two  instructive  cases  :^ 

Case  I. — The  injury  in  this  case,  Figure  330,  was  more  extensive 
than  would  ordinarily  be  repaired  by  plastic  surgery.  The  cervix 
uteri  to  the  level  of  the  internal  os,  the  vesicovaginal  and  urethro- 

'  Operations  in  the  case  of  Mrs.  G.  A.  M.,  at  St.  Luke's  Hospital.  Chicago. 


612 


TRAUMATISMS. 


vaginal  septum,  and  the  rectovaginal  septum  had  sloughed  away 
entirely ;  the  perineum  was  completely  lacerated  through  the  sphincter 
ani  muscle.  The  fundus  of  the  inverted,  ulcerated,  and  semi-stran- 
gulated bladder  protruded  through  the  pelvic  outlet ;  this  outlet  was 
bounded  by  the  sides  of  the  vulva,  by  the  posterior  and  lateral  mar- 
gins of  the  anus,  and  by  the  pubes.  Thus  all  control  of  both  urethra 
and  anus  was  lost.  The  uterus  was  occluded  by  contracted  cicatricial 
tissue  and  was  full  of  retained  menstrual  jfluid. 

Clearly  the  conditions  would   discourage  any   effort  to  repair  by 
ordinary  methods.     The  problem  Was  fourfold,  and  as  follows  : 

To  reopen  the  closed  uterine  canal  and  release  the  imprisoned 
menstrual  fluid. 

Figure  330. 


The  dotted  lines  indicate  the  parts  destroyed  by  slough.    The  perineum  was  not  destroyed,  but 

was  completely  torn  apart. 

To  replace  the  lost  vesicovaginal  septum. 

To  replace  the  lost  urethrovaginal  septum. 

To  replace  the  lost  rectovaginal  septum. 

To  reunite  the  si)hincter  ani  muscle. 

A  free  incision  with  sharp-pointed  scissors  into  the  uterus  reopened 
the  uterine  canal  and  re-established  normal  menstruation. 

The  labia  minora  were  much  hypertrophied,  and  were  therefore 
capable  of  supplying  abundant  material  for  the  replacement  of  the 
lost  vesicovaginal  wall ;  to  this  end,  they,  together  with  the  adjacent 
tissue  around  and  below  them,  were  dissected  off  from  above  down- 
ward, but  not  detached  at  their  lower  ends.     An  area  on  each  side 


GENITAL  FISTULA.  613 

just  within  the  vulva,  close  to  the  margin  of  the  bladder  mucous 
membrane,  was  freshened  by  denudation  and  splitting,  and  the  edge 
of  each  corresponding  labium  w^as  turned  in  and  stitched  to  this  area 
with  silkworm  gut  sutures.  The  flap  thus  formed  on  the  right  side 
united  perfectly  in  its  transplanted  position  ;  the  flap  on  the  left  side 
partly  sloughed  away.  The  right  transplanted  labium  now  took  its 
nutrition  through  the  lower  uncut  end  and  the  new  tissues  to  which  it 
was  united.  It  was  not  possible,  however,  at  the  first  transplantation 
to  carry  tlie  labium  sufficiently  high  to  unite  it  with  the  upper  margin 
of  the  fistula  because  it  would  not  reach  far  enough  to  fill  out  the 
space  left  by  the  sloughed-out  vesicovaginal  septum  ;  in  order  to 
make  it  reach,  the  transplanting  operation  had  to  be  done  three 
times — that  is,  the  labium  was  turned  end  for  end  upon  itself  three 
times,  and  finally  planted  in  place  of  the  lost  vesicovaginal  Avail. 
One  face  of  this  labium  was  now  the  bladder  side,  and  the  other 
was  the  vaginal  side  of  the  restored  vesicovaginal  wall.  In  order 
to  maintain  the  nutrition  of  the  flap  during  the  period  of  its  trans- 
plantation several  months  were  allowed  to  intervene  between  the 
transplanting  operations.  Finally,  after  numerous  attempts,  in  which 
sometimes  a  little  was  gained  and  sometimes  nothing,  the  margins  of 
the  flap  were  united  to  the  margins  of  the  opening  at  every  point  and 
the  integrity  of  the  vesicovaginal  septum  was  restored. 

The  urethra  was  repaired  by  denuding  two  parallel  strips,  three- 
quarters  of  an  inch  apart,  on  either  side  of  the  urethral  site,  and  unit- 
ing them  one  to  the  other  by  interrupted  silkworm  gut  sutures.  This 
formed  a  new  urethrovag-inal  wall.  The  remnant  of  the  left  labium 
minus  was  utilized  in  this  part  of  the  work.  The  urethra  thus 
formed  immediately  gave  a  measurable  degree  of  retentive  power 
when  the  woman  was  lying  do\vn.  The  bladder,  however,  Avas  much 
contracted  from  cystitis,  and,  having  but  small  capacity,  was  at  first 
of  necessity  often  evacuated. 

The  rectovaginal  septum  w^as  replaced  by  drawing  dov,n  the  loose 
rectal  wall  from  above  into  the  gap,  and  after  denudation  uniting  it 
to  the  lateral  walls  of  the  vagina  with  fine  buried  catgut  sutures.  At 
the  same  time  the  completely  ruptured  perineum,  including  the 
sphincter  ani  muscle,  was  reunited.  The  bowel  and  sphincter  muscle 
at  once  resumed  their  normal  functions.  Nineteen  operations  in  all 
were  performed  before  this  result  was  reached. 

The  patient,  two  years  after  her  discharge  from  the  hospital, 
reported  perfect  control  of  the  bowel  and  practically  perfect  control 
of  the  urethra.  In  a  letter  Mritten  at  that  time  she  said  :  "  I  have 
almost  perfect  control  of  the  urine  at  all  times ;  I  say  almost  because 
of  there  being  a  slight  weakness  at  times  ;  but  it  is  not  often,  and  even 
then  the  amount  of  leakage  is  not  great.  I  have  taken  up  the  study 
of  shorthand,  typewriting,  and  telegraphy,  and  if  I  make  a  success 
of  it  shall  feel  that  my  life  has  not  been  a  failure." 

This  case,  a  curiosity  in  surgery,  illustrates  what  may  sometimes 
be  accomplished  by  sustained  effort ;  little  by  little,  line  by  line,  in 
the  face   of  one  discouragement  after  another,  the  work  was  done. 


614  TEA  UMA  TISMS. 

The  treatment  continued  over  a  period  of  more  than  two  years,  with 
an  intermittent  period  of  three  years,  when  nothing  was  done.  Most 
of  the  time  it  seemed  like  following  the  forlorn  hope  ;  now  total  fail- 
ure, now  a  little  success,  until,  finally,  nineteen  operations  under 
anaesthesia  had  l)een  done.  "Words  fail  to  describe  the  bravery  and 
patience  displayed  by  this  woman,  or  the  difficulties  and  discourage- 
ments which  the  surgeon  must  meet  in  such  a  case. 

Case  11} — The  entire  vesicovaginal  septum,  the  vaginal  portion, 
of  the  cervix,  and  the  anterior  wall  of  the  cervix  to  the  internal  os 
had  sloughed  away,  leaving  no  bladder  tissue  between  the  inner  ex- 
tremity of  the  urethra  and  a  point  corresponding  to  the  plane  of  the 
internal  os  uteri.     See  Figure  331.     The  upper  and  lower  fragments 

FiorEE  331. 


The  dotted  lines  show  the  parts  which  had  sloughed  out.    Red  line  shows  remaining  portion 

of  bladder-wall. 

of  the  opening  could  not  be  approximated — that  is,  the  anterior  wall 
of  the  uterus  could  not  be  approximated  to  the  neck  of  the  bladder 
after  the  method  shown  in  Figure  329.  The  only  operation  which  at 
first  seemed  possible  was  to  unite  the  posterior  wall  of  the  cervix 
uteri  to  the  neck  of  the  bladder,  as  shown  in  Figure  329.  This 
would  have  turned  the  cervix  uteri  into  the  bladder,  and  menstruation 
would  have  taken  place  through  the  urethra.  But  while  this  was 
under  consideration  it  was  found,  on  further  examination,  that  the 
mucous  membrane  of  the  bladder,  if  caught  with  the  tenaculum  about 
an  inch  in  front  of  the  uterus,  could  be  drawn  to  the  neck  of  the  bladder 

1  E.  C.  Dudley.    Journal  American  Medical  Association,  March  27, 1886. 


GENITAL  FISTULM 


615 


— that  is,  to  the  lower  margin  of  the  fistula — and  held  there  without 
undue  traction.  A  strip  of  mucous  membrane  across  the  bladder  M-as 
therefore  denuded  from  side  to  side  an  inch  in  front  of  the  uterus. 
This  denudation  was  continued  around  the  lateral  and  lower  margins 
of  the  fistula.  The  strip  of  denuded  surface  across  the  bladder  was  then 
drawn  down  and  stitclied  to  the  lower  margin  of  the  fistula  X  Z,  Figure 
332.  Thus  the  bladder  was  divided  into  two  parts,  the  upper  closed 
part  communicating  with  the  urethra  and  receiving  the  urine  from  the 
ureters ;  the  lower  open  part  replacing  the  lost  anterior  vaginal  wall. 
In  other  words,  the  part  of  the  bladder-wall,  situated  between  the 
line  of  denudation  across  the  fundus  of  the  bladder  and  the  uterus, 
was  utilized  as  a  substitute  for  the  lost  vesicovaginal  septum  and 
anterior  wall  of  the  cervix.     Twenty-two  sutures  were  used.     Xot- 

FiGURE  332. 


Section  at  X  z  shows  the  fundus  of  the  bladder  stitched  to  the  neck  of  the  bladder. 


withstanding  the  failure  of  the  nurse  on  the  third  day  to  keep  the 
catheter  in  place,  and  the  consequent  accumulation  of  several  ounces 
of  urine  in  the  bladder,  union  by  first  intention  was  complete.  The 
bladder,  although  reduced  in  size  by  the  operation,  has  normally  per- 
formed its  functions  ever  since.  It  is  large  enough  to  enable  the 
woman  to  retain  her  urine  all  night.  The  writer  is  not  aware  that 
another  similar  operation  has  been  recorded. 

Howard  Kelly  suggests  a  plan  which  might  be  adopted  to  advan- 
tage in  place  of  the  one  just  described.  It  is  to  dissect  the  bladder 
entirely  free  from  the  uterus,  so  as  to  make  a  wide  opening  between 
the  vagina  and  the  peritoneum — that  is,  to  make  an  anterior  vaginal 
section  into  the  peritoneal  cavity.     The  bladder-wall,  anterior  to  the 


616 


TRAUMATISMS. 


uterus,  thus  freed  from  its  uterine  attachments,  may  then  be  drawn 
down  so  as  to  close  the  fistula  by  a  transverse  line  of  sutures.  Since 
the  bladder-wall  is  covered  with  peritoneum,  and  since  peritoneal  sur- 
faces are  very  prone  to  unite  readily,  such  an  operation  would  be  very 
apt  to  succeed.  After  closure  of  the  fistula  the  wound  anterior  to  the 
uterus  should  be  closed. 

Figure  333. 


Shows  act  of  splitting  margins  of  fistula  preparatory  to  approximating  the  fragments  of  the 
vesical  plate  of  the  vesicovaginal  wall.    Lateroprone  position  and  Sims'  speculum. 


Another  possible  method,  suggested  by  IMackinrodt/  for  such  cases 
Is  to  detach  the  vesical  from  the  vaginal  plate  of  the  vesicovaginal 
wall  and  to  close  the  fistula  by  suturing  together  the  vesical  plate 
independentlv,  leaving  the  vaginal  plate  open  to  heal  by  granulation. 
Figures  3-33  'and  .334! 

1  Centrablatt  fiir  Gynakologie,  No.  8,  1894;  from  Kelly. 


GENITAL  FISTULA. 
VESICOUTERINE  FISTULA. 


617 


This  form  of  fistula  has  been  mentioned  in  the  chapter  on  Lacer- 
ation of  the  Cervix;  it  is  the  result  of  anterior  laceration  of  the 
cervix  extending  into  the  bladder.  Usually  the  effort  of  nature  to 
repair  produces  union  in  the   lower  part  of  the   laceration  so  as  to 


Figure  334. 


Fistula  being  closed  by  union  of  vesical  plate  of  the  vesicovaginal  wall ;  this  leaves  the 
vaginal  plate  still  open.    Latero. 

repair  the  whole  vaginal  ]5art  of  the  injury  and  to  leave  the  uterine 
part  open.  Figure  292  shows  the  sinus  extending  from  the  bladder 
to  the  interior  of  the  uterus. 

The  Diagnosis  and  Treatment  of  Vesico-uterine  Fistula. 

The  diagnosis  is  based  upon  the  history  of  the  case  and  the  passage 
of  urine  through  the  os  externum.    The  treatment  is  to  reproduce  the 


618  TEA  UMA  TISMS. 

original  tear  by  an  incision  through  the  anterior  lip  of  the  cervix 
directly  into  the  sinus.  The  fistula  thus  exposed  at  the  angle  of  the 
incision  is  denuded,  and  the  whole  wound,  including  the  fistula  and 
the  cervical  laceration,  is  closed  with  silkworm  gut  sutures.  Except 
that  the  sutures,  in  addition  to  closing  the  cervix,  are  made  also  to 
close  the  opening  into  the  bladder,  the  operation  does  not  differ  from 
the  ordinary  operation  for  closure  of  an  anterior  laceration  of  the 
cervix  uteri. ^ 

URETHROVAGINAL  FISTULA. 

This  form  of  fistula  may  be  made  intentionally  by  a  surgical 
operation  in  the  treatment  of  urethritis  and  other  diseases  of  the 
urethra ;  it  is  occasionally  the  result  of  ulcerative  processes.  If  the 
neck  of  the  bladder  is  not  involved,  the  functional  power  of  the 
urethra  to  retain  urine  may  be  unimpaired.  The  operation  for 
closure  is  the  same  as  that  described  for  vesicovaginal  fistula.  The 
after-treatment  consists  of  the  hot-water  douche  twice  daily.  The 
self-retaining  catheter  is  not  required.  Ordinary  catheterization  is 
permissible,  but  if  the  woman  can  pass  urine  without  help,  it  is  not 
required. 

URETEROVAGINAL  FISTULA. 

Ureterovaginal  fistula  may  be  : 

I.  Congenital ;  one  or  both  ureters  may  open  into  the  vagina. 
II.  Acquired. 

Causes  of  Ureterovaginal  Fistula. 

The  causes  of  aquired  ureterovaginal  fistula  are  : 

1.  Sloughing,  due  to  pressure-necrosis  during  labor. 

2.  Necrotic  processes,  due  to  malignant  or  specific  disease. 

3.  Traumatisms,  usually  surgical. 

Diagnosis  of  Ureterovaginal  Fistula. 

The  diagnosis  is  made  by  passing  a  ureteral  catheter  into  the  ureter 
at  the  point  whence  the  urine  escapes.  In  the  congenital  form  there 
is  no  communication  between  the  ureter  and  the  bladder.  The 
acquired  form  mav  or  may  not  be  associated  with  a  vesicovaginal 
fistula.  If  so  associated,  the  ureteral  opening  is  usuallv  in  the  margin 
of  the  vesical  opening.  This  combination  is  called  ureter o-vesico- 
vaginal  fistula.  If  there  is  no  vesicovaginal  fistula,  the  urine  from 
one  kidney  only  will  escape  throus^h  the  vagina ;  that  from  the  other 
will  pass  naturally  through  the  urethra.  If  the  defect  is  bilateral, 
both  ureters  will  open  into  the  vagina. 

Treatment  of  Ureterovaginal  Fistula. 

The  treatment  of  a  uretero-vesicova^inal  fistula  is  as  follows  : 
-t  irst,  split  the  ureterovesical  wall  for  a  little  distance  back  from  the 

'  Emmet,    Principles  and  Practice  of  Gynecology,  second  edition,  p.  635. 


GENITAL  FISTULM  619 

margin  of  the  vesical  opening.  This  makes  a  new  and  larger  opening 
for  the  ureter  into  the  bladder  remote  from  and  out  of  the  way  of  the 
vesicovaginal  fistula.  The  latter  may  then  be  closed  in  the  usual 
manner. 

If  the  ureterovaginal  fistula  is  not  associated  with  a  vesical  open- 
ing, it  should  be  converted  into  a  uretero-vesicovaginal  fistula  by  an 
incision  at  the  ureterovaginal  outlet  directly  through  into  the  bladder. 
The  operation  then  is  continued  as  described  above  for  a  uretero-vesico- 
vaginal fistula. 

Dudley  Clamp  Operation. — I  present  herewith  the  report  of  a 
unique  case  in  which  stricture  of  the  ureter  was  a  possible  result  of 
laceration  of  the  cervix  uteri  and  ureterovaginal  fistula  a  result  of 
trachelorrhaphy.  ^ 

In  this  case  a  left  ureterovaginal  fistula  occurred  three  days  after 
introducing  some  rather  deep  sutures  for  the  control  of  secondary  hem- 
orrhage following  trachelorrhaphy.  About  one-half  of  the  urine 
escaped  from  the  left  ureter  into  the  vagina ;  the  remainder  passed 
naturally  through  the  urethra.  The  ureteral  bougie  passed  through  a 
Nitze  cystoscope  demonstrated  a  tight  stricture — possibly  obliteration 
of  the  ureter  near  the  opening  of  the  fistula  and  between  this  opening 
and  the  ureteral  orifice  in  the  bladder. 

About  four  weeks  after  the  accident,  with  the  purpose  of  perform- 
ing some  operation  to  re-establish  a  free  communication  between  the 
injured  ureter  and  the  bladder,  I  etherized  the  patient,  and  for  more 
than  three-quarters  of  an  hour  with  uterine  tenacula  and  a  fine  probe 
sought  in  vain  for  the  point  where  the  ureter  opened  into  the  vagina. 
No  urine  came  through  to  mark  this  point,  and  even  after  some  rather 
extensive  dissection  Avith  the  scissors  I  was  unable  to  locate  the  fistula, 
nor  was  I  able  to  make  out  the  ureter  by  palpation.  Finally,  how- 
ever, a  little  spurt  of  urine  appeared  just  to  the  left  of  the  cervix 
uteri,  but  I  was  unable  at  this  point  to  pass  even  a  Yery  fine  probe. 
Each  attempt  only  resulted  in  the  making  of  a  false  passage — a  thing 
difficult  to  avoid  under  such  conditions.  I  then  made  a  colpocys- 
totomy,  cutting  with  the  scissors  through  the  vesicovaginal  wall  in  the 
median  line  and  in  the  long  axis  of  the  vagina  just  in  front  of  the 
cervix.  The  vesicovaginal  fistula  thus  made  was  an  inch  long.  The 
upper  extremity  of  it  terminated  close  to  the  anterior  wall  of  the 
cervix  uteri.  With  a  pair  of  straight  scissors  I  then  extended  the 
incision  upward,  and  to  the  left  as  nearly  as  could  be  estimated,  to  the 
point  whence  the  urine  had  escaped.  The  object  was  if  possible  to  con- 
vert the  ureterovaginal  fistula  into  a  uretero-vesicovaginal  fistula;  so  that 
the  ureter  should  open,  not  into  the  vagina,  but  into  the  margin  of  a 
vesicovaginal  fistula.  After  another  long  search  I  again  failed  to  find 
the  fistulous  opening  into  the  ureter,  until  it  was  located  by  another 
spurt  of  urine,  but  the  opening  again  was  too  small  to  admit  a  fine 
probe,  and  therefore  could  not  be  entered.  I  then  still  further 
enlarged  the  vesicovaginal  fistula  in  a  direction  to  the  left  of  the 
uterus,  and  by  good  fortune  opened  into  a  very  much  dilated  ureter, 
from  which  immediately  there  gushed  two  or  three  ounces  of  pent- 

1  Boston  Medical  and  Surgical  Journal,  volume  cxlii.  No.  9. 


620 


TRAUMATISMS. 


up  urine.    A  ureteral  bougie  was  now  passed  without  obstruction  to  the 
kidney. 

The  situation  now  being  much  simplified,  the  following  procedures 
were  adopted  :  The  bladder  mucosa  was  stitched  to  the  vaginal 
mucosa  all  around  the  artificial  vesicovaginal  fistula.  In  this  way 
the  exposed  surfaces  were  covered  and  hemorrhage  controlled.  A 
haemostatic  forceps,  with  handles  about  four  inches  long  and  with 
slender  jaws  about  an  inch  long,  was  passed  through  the  vesicovaginal 
fistula.  Figure  335.  The  forcep  jaws  were  then  passed,  one  into  the 
ureter  and  the  other  into  the  bladder,  so  that  the  forceps  when  locked 
included  in  their  bite,  ureteral  wall,  bladder-wall,  and  the  connective 
tissue  between.     In  this  way  the  lower  extremity  of  the  cut-off  ureter 

Figure  335. 


CORPUS 
UTER 


Author's  operation  for  iireterovaginal  fistula. 

was  clamped  into  close  relations  with  the  bladder.  The  expectation 
was  that  the  structures  within  the  bite  of  the  forceps  would  be 
destroyed  by  pressure-necrosis,  and  that  a  wide,  free,  ureterovesical 
opening  would  be  established  at  a  point  somewhat  distant  from  the 
artificial  opening  into  the  bladder,  and  that  in  this  way  the  case  would 
become  one  of  uncomplicated  vesicovaginal  fistula.  The  forceps  came 
off  in  about  three  days,  and  twelve  days  later  the  vesicovaginal 
fistula  was  closed  by  suture  in  the  ordinary  way.  At  the  time  of 
this  operation  the  new  ureteral  orifice  was  found  to  be  perfectly  open 
and  very  patulous.  The  subsequent  history  was  uncomplicated, 
union  was  complete,  and  in  a  short  time  the  patient  was  discharged 
cured.     In  a  letter  written  about  six  months  after  the  final  operation 


GENITAL  FISTULA.  621 

the  patient  reported  entire  freedom  from  pain  in  the  left  inguinal 
region  from  which  she  had  suffered,  and  which  had  made  her  a 
semi-invalid  for  twenty  years.  I  regret  that  the  ureter  was  not 
explored  before  the  operation  on  the  cervix  uteri,  and  that  it  has  not 
been  practicable  to  obtain  measurements  of  it  since. 

My  experience  in  the  surgical  treatment  of  ureterovaginal  fistula 
is  limited  to  two  other  cases,  one  traumatic  and  one  congenital.  In 
these  two  cases  I  operated  at  St.  Luke's  Hospital,  Chicago,  seven 
or  eight  years  ago.  The  operative  treatment  in  each  was  like  that 
just  described,  except  the  ureteral  and  vesical  walls  were  divided  by 
scissors  instead  of  being  clamped  by  pressure-forceps.  In  these  cases, 
however,  the  ureteral  openings  were  much  nearer  to  the  trigone,  and 
the  lower  extremity  of  the  injured  ureter,  therefore,  was  quite  close 
to  the  bladder  mucosa. 

In  the  case  just  reported  the  distance  and  amount  of  tissue  between 
the  bladder  and  ureter  was  so  great  that  it  could  hardly  have  been 
divided  with  the  scissors  without  danger  of  uncontrollable  hemorrhage 
or  of  the  exposure  of  broad  surfaces  to  reunite,  or  to  cicatrize  and 
contract.  These  difficulties  were  obviated  by  clamping  the  ureter 
into  close  contact  with  the  bladder,  so  that  when  the  forceps  came 
off,  the  exposed  surfaces  left  by  the  necrosis  would,  owing  to  the  com- 
pression, be  of  small  extent.  The  compression-forceps  used  in  this 
way,  therefore,  may  make  the  operation  practicable  in  those  regions 
where  the  tissue  between  the  ureter  and  the  bladder  is  too  abundant 
to  be  divided  safely  by  scissors. 

It  is  hoped  that  this  operation  will  give  great  security  against 
subsequent  stricture  at  the  new  ureteral  orifice — a  result  not  obtain- 
able by  any  of  the  usual  procedures. 

Traumatic  ureterovaginal  fistula  as  a  result  of  trachelorrhaphy  is 
rare,  but  as  a  result  of  vaginal  hysterectomy  and  other  vaginal  sec- 
tions is  not  of  infrequent  occurrence.  The  operation  above  described 
is  applicable  to  the  condition^  whatever  the  cause,  whether  traumatic 
or  congenital. 

The  alternatives  to  the  operation  are  w^ell  know-n,  and  need  not  be 
described.  To  open  the  abdomen,  sever  the  ureter  and  insert  it  into 
the  bladder-wall,  is  an  operation  of  great  difficulty  and  danger,  and 
sometimes  is  of  only  transient  value.  The  same  may  be  said  of  dis- 
secting or  stripping  the  bladder  from  the  pelvic  wall,  finding  the 
ureter  and  inserting  it  into  the  bladder,  without  invading  the  peri- 
toneal cavity.  The  utilization  of  the  vaginal  mucosa  in  a  plastic 
operation  for  the  purpose  of  diverting  the  urine  from  the  vagina  to  the 
bladder  usually  results  in  failure  of  union,  or,  later,  in  cicatricial  con- 
traction and  consequent  stricture  of  the  ureteral  orifice.  The  opera- 
tion of  switching  the  ureter  into  the  intestine  or  into  the  opposite 
ureter  is  of  very  questionable  propriety. 

As  a  corollary  to  the  case  just  described,  the  folloMing  observa- 
tion, if  well  founded,  may  prove  to  have  practical  significance.  It 
is  probable  in  this  case  that  the  laceration  having  extended  into 
the  parametria  had  torn  the  structures  around  the  ureter.  There  may 
also  have  been  injurious  pressure  by  the  presenting  part  of  the  child 
38 


622  TRAUMATISMS. 

against  the  ureter.  Such  lacerated  tissues  would  necessarily  heal  by- 
cicatrization  and  contraction,  and  the  cicatrix  thus  formed  would 
draw  the  bruised  ureter  toward  the  uterus,  compress  it,  and  so  give 
rise  to  obstruction  both  from  stricture  and  from  kinking.  Contract- 
ing cicatricial  tissue  extending  from  the  cervix  around  the  ureter 
would  necessarily  draw  the  ureter  into  closer  proximity  to  the  uterus, 
where  a  deep  suture  applied  for  closure  of  the  cervix  or  to  control 
bleeding  would  be  apt  to  wound  it,  or  by  compression  cause  a  narrow- 
ing of  the  lumen  of  that  part  lying  within  its  grasp.  In  the  case 
described  the  stricture  extended  at  least  a  half-inch  on  either  side  of 
the  ureteral  fistula.  It  was  evidently  this  constricted  portion  of  the 
ureter  that  was  caught  by  the  needle  and  cut  off  or  penetrated  by  the 
suture. 

It  would  be  quite  impossible,  without  further  observation,  to  esti- 
mate the  proportion  of  cases  in  which  laceration  of  the  cervix  uteri 
causes  stricture  or  kinking  of  the  ureter.  Every  gynecologist  may 
revert  to  a  class  of  cases,  not  small,  in  which  there  is  extensive  lacera- 
tion of  the  cervix  uteri  on  one  or  both  sides,  and  in  which  the  localized 
pain  dating  from  the  puerperium  is  not  readily  accounted  for  by  pal- 
pable lesions,  and  is  not  relieved  in  the  slightest  degree  by  the  repair 
of  the  cervix.  As  I  look  back  over  a  long  experience  I  recall  many 
such  cases,  and  among  them  the  one  just  reported. 

But  why,  one  may  ask,  if  the  ureter  is  often  drawn  by  cicatricial 
contraction  close  to  the  uterus,  is  it  not  more  frequently  injured  by 
operations  on  the  cervix  ?  The  answer  is  that  if  the  sutures  of 
trachelorrhaphy  were  not  usually  introduced  close  to  the  uterus  or 
very  superficially  in  the  vaginal  wall,  more  cases  of  ureterovaginal 
fistula  probably  would  be  reported.  This  case  was  very  hemorrhagic, 
and  therefore  required  exceptionally  deep  sutures  to  control  the  bleed- 
ing. In  view  of  the  facts  already  set  forth,  I  desire  to  submit  two 
questions,  as  follows : 

Question  1.  In  all  cases  of  extensive  laceration  of  the  cervix  uteri, 
in  which  the  localized  pain  is  not  accounted  for  by  palpable  lesions, 
should  we  not  pass  a  series  of  graduated  ureteral  bougies  on  the  side 
corresponding  to  the  laceration  ?  This  would  be  for  the  purpose  of 
measuring  the  calibre  of  the  ureter  and  of  locating  a  possible  strict- 
ure. The  principles  of  examination  would  be  similar  to  those  of 
measuring  the  calibre  of  the  male  urethra  in  the  diagnosis  of 
stricture. 

Question  2.  In  a  case  of  ureteral  stricture  due  to  laceration  of  the 
cervix  uteri,  or  to  any  other  cause,  and  situated  within  the  range  of 
a  vaginal  operation,  would  not  the  surgeon  be  warranted  in  opening 
the  bladder  and  then  proceeding,  as  in  the  case  reported,  to  establish 
a  new  ureteral  orifice  ?  In  other  words,  should  not  that  condition 
which  in  this  case  was  the  result  of  an  accident,  be  reproduced 
deliberately  in  similar  cases? 

My  answer  to  these  questions  would  be  in  the  affirmative. 

Dr.  Edward  Reynolds  ^  has  reported  a  successful  case  of  a  damp 

1  Boston  Medical  and  Surgical  Journal,  January  24, 1901. 


GENITAL  FISTULM  623 

operation  hy  the  method  above  described.  Cystoscopic  examination 
after  the  recovery  of  the  jDatient  showed  a  ureteral  orifice  which, 
except  the  high  location,  presented  all  the  appearance  of  the  natural 
orifice. 

Accidental  Wounding  of  the  Ureter  in  Vaginal  Hysterectomy. — On 
April  22,  1903,  I  performed  vaginal  hysterectomy  for  carcinoma 
of  the  corpus  uteri  upon  a  woman  seventy  years  of  age,  a  patient 
of  Dr.  Lord,  of  Piano,  Illinois,  whose  pelvic  organs  long  since 
had  passed  into  extreme  senile  atrophy.  In  making  the  opening 
into  the  peritoneal  cavity  between  the  bladder  and  the  uterus  the 
carcinomatous  disease  had  extended  so  far  anteriorly  that  the  bladder 
was  opened  immediately  in  front  of  the  cervix  uteri.  An  opening 
into  the  peritoneum  posterior  to  the  uterus  was  made  without  accident, 
the  broad  ligaments  then  were  isolated  and  cut  close  to  the  uterus 
and  the  uterus  removed.  After  cutting  through  the  right  broad  liga- 
ment a  spurt  of  fluid  was  observed,  which  upon  examination  proved 
to  have  come  from  the  right  ureter,  showing  that  the  ureter  had  been 
divided.  This  accident  to  the  ureter  was  consequent  upon  the  fact 
that  the  cicatricial  tissue  of  an  old  cervical  laceration  had  caught  it 
and  drawn  it  into  close  relation  with  the  uterus  into  the  line  of 
incision.     Figure  336. 

After  a  hasty  consultation  with  Dr.  Kolischer,  who  chanced  to  be 
present,  it  was  decided,  if  possible,  to  establish  a  direct  communica- 
tion between  the  upper  cut  end  of  the  ureter  and  the  interior  of 
the  bladder.  The  usual  method  of  performing  this  operation  is  to 
make  an  opening  into  the  bladder,  push  the  end  of  the  ureter  through, 
and  fasten  it  there  by  means  of  sutures.  Appreciating  the  well- 
known  tendency  of  the  cut  end  of  the  ureter  to  contract  when 
introduced  into  the  bladder  in  this  way,  and  having  at  hand  a  vesico- 
vaginal fistula  which  rendered  the  interior  of  the  bladder  quite  ac- 
cessible, I  made  use  of  a  method  which,  so  far  as  I  know,  had  not 
been  described.  With  a  long  slender  forceps  I  punctured  the  bladder 
wall  from  within  outward  at  the  point  nearest  to  the  cut  end  of  the 
ureter.  Then  after  splitting  the  cut  end  of  the  ureter  and  denud- 
ing the  bladder  mucosa  on  either  side  of  the  punctured  opening,  I 
drew  the  ureter  into  the  bladder.  Figures  337  and  338,  and  stitched 
it  there  by  means  of  fine  chromic  catgut  sutures.  Figure  339.  By  this 
means  the  split  end  of  the  ureter  was  held  widely  apart  by  means  of 
sutures,  so  that  it  could  not  easily  contract  and  form  a  stricture.  The 
tightly  fitting  ureter  made  the  punctured  bladder  wound  water 
tight. 

The  vesicovaginal  fistula  was  closed  immediately  by  drawing  the 
anterior  margin  of  the  peritoneum  down  to  the  lower  margin  of  the 
vaginal  wound  and  fastening  it  there  with  a  continuous  chromic  cat- 
gut suture.  In  like  manner  the  posterior  margin  of  the  perito- 
neum was  brought  into  contact  with  the  vaginal  margin  of  the  wound, 
after  which  the  wound  from  the  peritoneal  cavity  into  the  vagina  was 
closed  in  the  usual  way,  the  stumps  of  the  broad  ligaments  being 
drawn  down  into  the  vagina  and  fastened  there  by  means  of  sutures, 
one  at  each  end  of  the  vaginal  wound.     During  the  two  weeks  fol- 


624 


TRAUMATISMS. 


lowing  the  operation  the  bladder  was  kept  empty  by  the  continuous 
use  of  a  self-retaining  catheter. 

Cystoscopy  by  Dr.  Kolischer  and  myself  four  weeks  later  showed 
a  perfectly  patulous  opening  of  the  ureter,  the  divided  flaps  of  which 
were  united  firmly  to  the  bladder  mucosa. 

The  special  advantages  of  the  method,  as  already  pointed  out,  are 
twofold :  1.  A  Avater-tight  wound  around  the  ureter  where  it  enters 


FiGUEE  336. 


Figure  337. 


FiGiJEE  336.— Ureter  accidentally  cut  in  vaginal  hysterectomy.  The  upper  cut  end  leads 
from  the  kidney,  the  lower  end  to  the  bladder.    Semi-diagrammatic. 

FiGUBE  a37.— The  upper  cut  end  of  the  ureter  split  and  in  the  grasp  of  a  forceps  which  has 
previonsly  made  an  opening  from  the  interior  to  the  exterior  of  the  bladder  by  puncture. 
Semi-diagrammatic. 

FiGT-EE  338.— The  split  end  of  the  ureter  has  been  drawn  into  the  bladder  by  means  of  the 
forceps.    Semi-diagrammatic. 

FiGFEE  339.— The  split  end  of  the  ureter  having  been  drawn  into  the  bladder  and  the  blad- 
der mucosa  having  been  denuded  on  either  side  of  the  opening,  the  two  flaps  are  fastened  to 
the  denuded  mucosa  by  means  of  sutures,  three  on  each  side. 

the  bladder.  2.  Security  against  contraction  of  the  end  of  the  ureter 
where  it  enters  the  bladder.  These  advantages  in  a  similar  case 
would  lead  me  to  repeat  the  operation  if  the  bladder  happened  to  be 
opened,  and  I  would  be  inclined  to  make  an  artificial  vesicovaginal 
fistula  for  this  purpose  if  the  bladder  was  not  open. 


GENITAL  FISTULA.  625 

RECTOVAGINAL   FISTULA. 

Causes  of  Rectovaginal  Fistula. 

Parturitiou,  although  a  frequent  cause,  is  relatively  at  least  a  less 
frequent  cause  of  rectovaginal  than  of  vesicovaginal  fistula ;  the 
lesion  is  observed  more  commonly  as  the  result  of  syphilis  or  cancer. 
Occasionally  a  peri-anal  abscess  is  situated  in  the  perineum,  and  in 
the  acute  stage  breaks  into  both  the  vagina  and  the  lower  bowel ; 
or,  later,  the  perineum  may  be  perforated  from  the  anus  to  the 
vagina  by  the  burrowing  of  pus.  Such  cases  are  apt  to  be  syphilitic 
or  tuberculous. 

Diagnosis  of  Rectovaginal  Fistula. 

The  diagnosis  is  made  by  digital  or  speculum  examination  by  the 
probe,  or  by  injecting  milk  into  the  rectum  and  observing  the  point 
at  which  it  appears  in  the  vagina. 

Prognosis  of  Rectovaginal  Fistula. 

The  lesion,  when  due  to  cancer,  is  incurable  ;  when  the  cause  is 
syphilis,  the  operation  for  closure,  unless  precedecF  by  adequate  specific 
treatment,  usually  fails.  A  sinus  of  tubercular  or  other  inflammatory 
origin  should  be  successfully  closed  by  suture ;  but  the  prognosis  is 
much  improved  by  such  preliminary  treatment  as  will  improve  the 
general  nutrition.  In  fistula  due  to  pressure-necrosis  the  operation 
of  closure  by  suture,  although  beset  by  more  unfavorable  conditions 
than  in  urinary  fistulse,  usually  succeeds. 

Operation  for  Rectovaginal  Fistula. 

The  principles  are  the  same  as  for  urinary  fistula?.  The  prepara- 
tion is  the  same  as  for  closure  of  the  completely  lacerated  perineum — 
that  is,  free  catharsis  during  several  days  before  the  operation,  and 
the  use  of  such  food  and  intestinal  antiseptics  as  will  reduce  to  the 
minimum  the  amount  of  gas  and  other  contents  of  the  bowel ;  much 
depends  upon  making  the  bowel  as  nearly  as  possible  aseptic. 

The  operation  often  fails  from  the  pressure  of  gas  and  other  rectal 
contents  against  the  newly  united  wound  :  hence  in  order  to  give, 
during  the  healing  process,  a  free  outlet  for  the  rectum,  the  sphincter 
ani  muscle  should  be  stretched. 

The  denudation  and  passage  of  sutures  should  be  on  the  vaginal 
side  of  the  rectovaginal  wall,  and  should  extend  to  but  not  into  the 
rectal  mucosa.  The  object  is  to  make  the  operation,  so  far  as  pos- 
sible, in  the  more  favorable  soil  of  the  vagina.  In  order  to  insure 
thorough  denudation  of  the  whole  sinus  clear  to  the  margins  of  intes- 
tinal mucosa,  the  index-finger  of  the  left  hand  in  the  bowel  is  made 
to  roll  the  rectal  margin  toward  the  vaginal  opening,  and  thereby 
render  it  accessible  for  denudation  by  means  of  properly  curved 
scissors.     In  a  very  small  fistula  the  sinus  may  be  inaccessible  for 


626  TBA  UMA  TISMS. 

denudation  until  it  has  been  made  so  by  free  incision  on  the  vaginal 
side.  Such  incision  should  not  extend  into  the  rectum.  As  in  urin- 
ary fistulse,  broad  surfaces  for  union  should  be  denuded  on  the  vaginal 
wall.     The  method  of  suture  is  the  same  as  for  vesicovaginal  fistula. 

ANOVAGINAL   FISTULA. 

The  causes,  diagnosis,  and  prognosis  are  much  the  same  as  given 
above  for  rectovaginal  fistula.  The  sinus  runs  through  the  perineum, 
and  may  therefore  be  inaccessible  for  denudation,  in  which  case  it 
should  be  laid  open  by  an  incision  on  the  vaginal  side  of  the  peri- 
neum, but  not  necessarily  through  the  whole  sphincter  ani  muscle. 
Most  operators,  however,  divide  the  entire  perineum  between  the 
sinus  and  the  cutaneous  side  of  the  perineum.  The  remaining  steps 
of  the  operation  then  are  to  denude  freely  and  deeply  the  now  ex- 
posed walls  of  the  sinus,  and  then  to  close  the  wound  as  in  the  opera- 
tion for  complete  laceration  of  the  perineum.  The  advantage  of 
complete  division  lies  in  the  immobilization  of  the  sphincter  ani 
muscle,  for  unless  severed,  this  muscle  may,  by  continuous  relaxation 
and  contraction,  imperil  union.  Entire  division  of  the  muscle  or 
division  of  all  but  a  few  fibres  of  it  is  preferable  to  divulsion.  The 
after-treatment  of  the  operation  for  closure  of  the  fistula  is  the  same 
as  for  complete  perineorrhaphy. 


PART    V. 

DISPLACEMENTS  OF  THE  UTERUS  AND 
OTHER  PELVIC  ORGANS. 


CHAPTER    XLIV. 

DISPLACEMENTS  OF  THE  UTERUS. 

General  Considerations. 

The  title  of  this  chapter  is  not  to  be  taken  in  a  restricted  sense, 
for  the  uterus  is  anatomically  so  connected  with  adjacent  organs  that 
the  displacements  of  it  cannot  be  considered  intelligently  nor  pre- 
sented satisfactorily  without  at  the  same  time  incidentally  taking  into 
account  the  displacements — causative,  resultant,  and  concurrent — of 
the  ovaries,  Fallopian  tubes,  rectum,  vagina,  bladder,  and  perineum. 

The  following  pathological  sequence  will  serve  as  an  example. 
The  vaginal  outlet  may  be  so  injured  in  labor  as  to  cause  displace- 
ment of  the  perineum  backward  toward  the  coccyx,  where  it  can  no 
longer  serve  as  a  bulwark  against  the  downward  force  which  is  exerted 
in  the  expulsion  of  the  contents  of  the  bladder  and  rectum.  The 
force  of  straining  at  stool  and  of  urination  is  now  exerted  against  the 
less  resisting  bladder  and  rectal  M-alls  ;  they  consequently  pouch  into 
the  vaginal  outlet.  The  downward  displacements  thereby  produced 
are  called  cystocele  and  rectocele.  The  vaginal  w^alls  are  attached  to 
the  uterus,  and,  being  displaced  downward,  must,  by  traction,  pull 
that  organ  to  a  lower  level.  The  uterus  in  turn  is  connected  with  the 
bladder,  rectum,  Fallopian  tubes,  and  ovaries,  and  in  its  own  descent 
draws  these  organs  out  of  place  and  disturbs  their  relation  to  one 
another.  This  shows  how  a  uterine  displacement  may  be  both  causa- 
tive and  resultant.  Concurrent  displacement  of  the  uterus  and  other 
pelvic  organs  may  result,  for  example,  from  the  dow'nward  pressure  of 
a  tumor  or  from  inflammatory  causes. 

It  is  convenient,  because  conformable  to  usage,  to  treat  the  sub- 
ject of  displacements  of  the  pelvic  organs  under  the  heading  Uterine 
Displacements.  At  the  same  time  it  must  be  held  clearly  in  mind 
that  a  uterine  deviation  may  not  be  the  essential  factor  in  the  morbid 
sequence  ;  on  the  contrary,  it  may,  as  already  stated,  be  only  an  inci- 
dent. The  subject,  therefore,  properly  includes  the  displacements  not 
merely  of  the  uterus,  but  of  all  the  pelvic  organs.     It  further  em- 

627 


628  DISPLACEMENTS. 

braces  the  relations  which  these  displacements  may  bear  to  one  another, 
and  to  such  associated  lesions  as  inflammation,  tumors,  traumatisms, 
and  congenital  defects. 

The  importance  of  a  distinction  between  location  and  position  will 
become  apparent  hereafter  :  by  the  former,  is  meant  the  situation  of 
the  oro-an  regardless  of  its  attitude ;  by  the  latter,  is  meant  the 
attitude  alone.  To  change  an  object  from  one  place  to  another,  is  to 
change  its  location ;  to  turn  it  over  or  bend  it  upon  itself,  is  to  change 
its  Dosition. 

Normal  Position  of  the  Uterus. 

In  many  works  on  anatomy  and  gynecology  the  uterus  is  repre- 
sented as  having  a  straight  or  nearly  straight  canal — as  lying  about 
midway  between  the  symphysis  pubis  and  the  hollow  of  the  sacrum, 

Figure  340. 


Classical  representation  of  the  pelvic  organs. 

its  axis  corresponding  with  that  of  the  pelvic  inlet.  The  position 
being  one  of  slight,  and  only  slight,  anteversion  and  anteflexion,  many 
authorities  would  pronounce  the  organ  anteverted  or  anteflexed  to  a 
degree  that  would  endanger  health  if  by  digital  examination  its 
anterior  wall  could  be  felt  through  the  anterior  wall  of  the  vagina. 
This  classical  idea  of  the  normal  position  of  the  uterus  wrongly  pre- 
supposes a  distended  bladder  and  rectum  occupying  the  anterior  and 
the  posterior  thirds  of  the  pelvic  cavity.    Such  an  arrangement  would 


I)ISPLACEME2iTS  OF  THE   UTERUS. 


629 


leave  for  the  uterus  only  the  intermediate  space,  and  would  constitute 
a  condition  seldom  or  never  realized  in  health. 

Suppose  a  straight  line  coincident  with  the  vesicovaginal  wall, 
Figure  340,  to  be  continued  through  the  cervix  to  the  sacrum.  This 
line  represents  approximately  the  anteroposterior  diameter  of  the 
pelvis.  The  length  of  the  vesicovaginal  wall  is  two  and  a  half  inches, 
and,  supposing  the  cervix  to  be  just  midway  between  the  symphysis 
and  the  sacrum,  the  distance  from  its  posterior  wall  to  the  sacrum 
must  also  be  two  and  a  half  inches.  Add  to  the  sum  of  these  two 
parts  of  this  anteroposterior  diameter  one  inch  for  the  diameter  of 
the  cervix,  and  the  anteroposterior  diameter  of  the  pelvis  becomes  six 
inches,  instead  of  the  normal  four  and  one-third,  which  proves  that 
the  cervix  must  normally  be  much  nearer  to  the  hollow  of  the  sacrum 
than  to  the  symphysis.  Since  the  length  of  the  vesicovaginal  wall 
plus  the  diameter  of  the  cervix  measures  three  and  one-half  inches, 

Figure  341. 


Correct  drawing  of  the  pelvic  organs.    Semi-diagrammatic. 


it  follows  that  the  distance  from  the  posterior  wall  of  the  cervix  to 
the  liollow  of  the  sacrum  must  be  the  diiference  between  four  and  one- 
third  and  three  and  one-half  inches,  or  five-sixths  of  an  inch.  These 
measurements  are  approximations. 

Again,  suppose  the  uterus,  Figure  340,  to  be  carried  bodily  upward 
and  backward,  its  axis  remaining  the  same,  until  the  cervix  reaches  its 


630  DISPLACEMENTS. 

normal  position  near  the  hollow  of  the  sacrum ;  then  would  the  body 
of  the  uterus  impinge  upon  the  bony  sacrum.  It  is  therefore  clear 
that  anteversion  must  be  the  normal  position,  because  the  uterus  and 
sacrum  would  otherwise  occupy  the  same  space. 

Figure  341  represents,  according  to  Schultze,^  the  location  and 
position  of  the  virgin  uterus  and  its  surroundings — the  bladder,  rec- 
tum, and  vagina  being  empty  and  collapsed.  The  angle  of  about  90 
degrees  which  the  cervix  forms  with  the  vagina  measures  the  forward 
inclination  of  the  cervix,  but  is  subject  to  variations  in  consequence 
of  the  physiological  movements  of  the  uterus.  The  body  further- 
more is  bent  forward  upon  the  cervix,  so  that  its  anterior  surface  rests 
upon  the  empty  bladder.  The  angle  of  normal  anteflexion,  according 
to  careful  measurements  by  Schultze,  is  about  48  degrees ;  Fritsch 
says  that  90  degrees  is  the  physiological  limit.  This  question  will  be 
considered  further  under  the  subject  of  pathological  anteflexions. 

Normal  Movements  of  the  Uterus. 

Strictly,  the  uterus  can  have  no  absolutely  normal  position  or  loca- 
tion, because  it  has  a  certain  normal  range  of  movements  that  depend 
to  some  extent  upon  respiration,  intra-abdominal  forces,  and  locomo- 
tion, but  more  especially  upon  the  varying  contents  of  the  rectum  and 
bladder.  The  normal  position  varies  within  the  limits  of  the  normal 
movements.  If  the  body  of  the  uterus  rests  upon  the  bladder,  it  must 
rise  as  the  bladder  becomes  distended ;  and,  conversely,  if  the  urine  be 
drawn  through  a  catheter  while  the  woman  is  lying  on  her  back,  the 
uterus,  notwithstanding  the  opposing  influence  of  its  own  weight, 
immediately  follows  the  receding  wall  of  the  bladder  and  returns 
through  an  arc  of  45  degrees,  or  possibly  even  90  degrees,  to  its 
accustomed  position. 

The  full  rectum  forces  the  uterus  in  the  opposite  direction,  toward 
the  symphysis,  and  thereby  counteracts  the  influence  of  the  full 
bladder.  This  anterior  movement  is,  however,  somewhat  limited, 
and  is  confined  to  the  cervical  portion,  except  when  the  body  has  been 
forced  back  into  close  proximity  with  the  rectum  by  the  overdistended 
bladder. 

Normal  Supports  of  the  Uterus. 

The  uterus  is  maintained  in  its  normal  position  and  location  by  the 
pelvic  floor,  of  which  the  uterine  ligaments  are  an  essential  part.' 

The  uterine  ligaments  are  physiologically  in  a  state  of  relaxation  ; 
the  state  of  tension  would  be  pathologi(!al ;  "they  do  not  fix  the  uterus; 
they  tend  only  to  limit  its  movements  to  their  "^normal  range.  Back- 
ward displacement  of  the  body  is  resisted  by  the  round  ligaments ; 
backward  displacement  of  the  cervix,  by  the'  uterovesical  ligaments 
and  by  the  vesicovaginal  wall.  Forward  and  downward  displace- 
ments are  resisted  by  the  uterosacral  ligaments,  and  excessive  lateral 

Ti«ri'i^'"??67  fur  Gynakologie,  1875,  Band  viii.  p.  134,  and  Lageveranderungen  der  Gebarmutter, 
thJ  ,\^',w;o  \  \^^.^^  ^^a^ke^  makes  a  full  and  critical  studv  of  the  normal  movements  of 
^^1  r.n^^Rjff^^i^'^  uterus,  m  the  >ew  York  Medical  Journal,  vol.  xxi.  p.  337;  and  of  the  nor- 
S^i  il?1  i?V?i  ^'^T??"^^^^^,  ^^.  'h^  unimpregnated  uterus,  in  the  American  Journal  of  Obstet- 
rics, voi.  XI.  p.  314.    ms  conclusions  substantially  agree  with  the  later  observations  of  Schultze. 


DISPLACEMENTS  OF  THE   UTERUS.  631 

motion  by  the  broad  ligaments.  This  restraining  power  is  doubtless 
greater  in  the  uterosacral  than  in  any  of  the  other  ligaments. 

The  Pelvic  Floor,  which  is  the  chief  support  of  the  uterus,  is  divided 
into  two  segments,  the  pubic  and  sacral.  The  pubic  segment  includes 
bladder,  urethra,  anterior  vaginal  wall,  and  bladder  peritoneum  ;  it 
is  attached  in  front  to  the  symphysis  pubis,  and  laterally  to  the  ante- 
rior bony  walls  of  the  pelvis.  The  sacral  segment  includes  rectum, 
perineum,  posterior  vaginal  wall,  and  strong  tendinous  and  muscular 
tissue  ;  it  is  attached  to  the  coccyx,  to  the  sacrum,  and  to  the  posterior 
wall  of  the  bony  pelvis. 

Permeating  the  pelvic  floor  in  all  directions,  entering  into  the  com- 
position of  its  single  parts,  binding  them  together,  and  sending  its 
processes  to  the  bony  pelvis,  is  the  pelvic  connective  tissue,  upon  the 
integrity  of  which  largely  depends  the  integrity  of  the  pelvic  floor  as 
a  uterine  support.  The  idea  that  the  uterus  is  supported  by  the 
vaginal  walls,  or  by  the  perineum,  or  by  the  uterine  ligaments  is 
obsolete ;  they  are  important  parts  of  the  pelvic  floor,  and  as  such 
contribute  support,  but  the  pelvic  floor  as  a  whole  supports  the  uterus. 
The  various  uterine  supports  are  to  a  great  extent  the  seat  of  motor 
influence.  They  consequently  not  only  resist  excessive  movement, 
but  also  serve  to  return  the  organ  from  its  physiological  migrations. 

Definition  and  Nomenclature  of  Displacements  of  the  Uterus. 

In  the  foregoing  pages  the  normal  location,  position,  movements, 
and  supports  of  the  uterus  have  been  outlined.  Those  conditions  are 
pathological  which  induce  changes  to  positions  or  locations  beyond 
the  defined  limits,  or  which  so  fix  the  organ  that  its  normal  move- 
ments are  prevented.  The  displacements  are  divided  into  mal-loca- 
tions  and  malpositions. 

The  mal-locations,  in  which  the  uterus  occupies  a  place  outside 
its  normal  limits,  are  as  follows  : 

Ascent.  Antelocation. 

Retrolocation.  Lateral  location. 

Descent. 
The  malpositions  are  determined  by  excessive  change  in  the 
inclination  of  the  uterine  axis.  They  are  divided  further  into 
flexions,  in  .which  the  organ  is  bent  upon  itself  in  an  abnormal  degree, 
manner,  or  direction  ;  and  versions,  in  which  the  axis  of  the  unflexed 
uterus  inclines  in  an  abnormal  degree  or  direction.  The  malpositions 
therefore  are : 

Retroversion.  Lateral  flexion. 

Retroflexion.  Anteversion. 

Lateral  version.  Anteflexion. 

Symptoms  and  Diagnosis  of  Displacements  in  General 
of  the  Uterus. 

Each  variety  of  displacement  may  be  indicated  by  its  own  group 
of  symptoms  and  physical  signs.  These  will  be  presented  in  the 
study  of  special  displacements.     To  avoid  repetition,  those  symptoms 


632  DISPLACEMENTS. 

and  signs  which  pertain  to  no  special  displacement,  but  which  belong 
to  all  alike,  will  be  mentioned  at  once.  They  may  arise  either  from 
the  displacement  itself  or  from  possible  complications,  of  which  the 
following  are  examples  :  metritis,  ovaritis,  salpingitis,  atresia,  stenosis, 
cystitis,  vesical  catarrh,  rectitis,  rectal  catarrh,  perimetritis,  peritonitis, 
uterine  catarrh,  tumors,  and  cicatrices. 

Uterine  displacement  may  be  a  cause  or  an  effect  of  associated  com- 
plications ;  or,  together  with  them,  it  may  be  a  concurrent  result  of  some 
common  cause ;  or  it  may  have  had  primarily  no  pathological  connec- 
tion with  them.  The  symptoms  of  displacement  refer  to  the  pelvic 
organs  or  to  the  nervous  system. 

Among  the  symptoms  or  associated  lesions  which  refer  to  the 
pelvic  organs  are  : 

Difficult  walking  and  standing.         Pelvic  pain. 

Dysmenorrhoea.  Menorrhagia. 

Sterility.  Frequent  abortion. 

Constipation.  Painful  or  difficult  defecation. 

Dysuria.  Polyuria. 

Tenesmus. 
Among   the  symptoms   or   associated  lesions    which  refer  to  the 
nervous  system  are : 

Xeuralgia  in  various  parts.  Motor  disturbances. 

Hysteria.  Nervous  dyspepsia. 

Anaemia.  Chlorosis. 

Spinal  irritation. 
The  final  diagnosis  must  depend  always  upon  direct  examination 
of  the  uterus  itself.  The  first  division  of  the  above  group  of  symp- 
toms is  not  likely  to  escape  notice  as  indicative  of  displacement,  but 
the  nervous  symptoms  are  disregarded  constantly  or  treated  without 
reference  to  their  possible  pelvic  origin.  The  frequent  dependence 
of  these  nervous  phenomena  upon  displacement  is  proved  by  their 
persistence  in  many  cases  after  ordinary  treatment,  by  their  prompt 
disappearance  upon  permanent  replacement  and  retention  of  the 
uterus  by  mechanical  means,  and  by  their  usually  prompt  recurrence 
upon  removal  of  the  support.  The  presence,  therefore,  of  the  second 
division  of  the  group,  or  any  part  thereof,  even  though  the  first  be 
absent,  will  justify  a  careful  investigation  into  the  state  of  the  pelvic 
organs. 

Examination  that  results  only  in  giving  the  name  to  a  special 
variety  of  displacement,  and  does  not  include  the  complicating  lesions, 
would  not  furnish  a  sufficient  guide  to  the  therapeutic  indications,  and 
is  therefore  inadequate.  Successful  treatment,  for  instance,  of  an 
anteflexion  dependent  upon  inflammation  of  the  uterosacral  ligaments 
must  include  removal  of  the  inflammation. 

An  important  prerequisite  to  examination  is  the  absence  of  con- 
tents in  the  rectum  and  bladder.  The  full  rectum  distorts  the  vaginal 
walls,  deprives  the  examiner  of  the  space  necessary  for  introduc- 
tion of  the  speculum,  and  throws  the  uterus  out  of' its  accustomed 
position.  Much  more  troublesome  is  the  presence  of  even  a  small 
quantity  of  urine  in  the  bladder,  because  it  makes  the  abdominal 


DISPLACEMENTS  OF  THE   UTERUS.  633 

muscles  tense  when  tlie  hand  is  placed  over  the  lower  portion  of  the 
abdomen  for  bimanual  palpation,  and  makes  it  difficult  to  engage  the 
uterus  between  the  hand  and  the  examining  finger.  The  distended 
bladder,  by  pushing  the  uterus  upward  and  backward,  makes  bimanual 
palpation  almost  useless.  It  is  not  surprising  that  conflicting  opinions 
are  common,  when  one  day  the  patient  is  examined  with  rectum  and 
bladder  full,  another  day  with  these  organs  empty ;  one  day  in  the 
dorsal,  another  day  in  Sims'  or  the  knee-breast  position  ;  one  day  with 
the  cylindrical  or  bivalve  speculum,  another  day  with  Sims'  or 
Simon's.  The  left-hand  method  of  examination  is  incomparably 
superior  to  the  right.  The  palmar  surface  of  the  left  index-finger  has 
a  more  acute  and  more  easily  educated  tactile  sense,  and  is  directed 
more  easily  toward  the  left  side  of  the  pelvis,  which  is  especially  sub- 
ject to  disease.  The  stronger  right  hand  should  be  free  to  palpate  the 
surface  of  the  abdomen  in  conjoined  manipulation. 

For  digital  examination  the  dorsal  position  is  preferred  :  the  patient 
should  be  drawn  close  to  the  edge  of  a  bed,  or  preferably  a  table,  the 
thighs  being  flexed,  the  feet  about  fifteen  inches  apart,  and  knees 
widely  separated.  The  examiner  should  stand  facing  the  patient  or 
at  her  left  side.  The  index-finger  of  the  left  hand,  properly  lubri- 
cated, then  slowly  advances  over  the  perineum  into  the  vagina,  noting 
the  condition  of  the  perineum,  the  presence  or  absence  of  cicatrices, 
lacerations,  tumors,  or  relaxation  of  the  vagina  or  perineum,  the 
capacity  of  the  vagina,  the  condition,  size,  and  direction  of  the  cer- 
vix, its  distance  from  the  sacrum  and  vulva,  its  mobility  or  fixa- 
tion. Now,  the  right  hand  is  pressed  well  down  behind  the  pubes, 
and  the  uterus  is  engaged  between  it  and  the  examining  finger.  See 
Chapter  III.  In  this  way  the  examiner  may  determine  quite  accu- 
rately the  position,  location,  and  size  of  the  entire  organ  ;  may  detect 
the  possible  presence  of  complicating  tumors,  both  inflammatory  and 
non-inflammatory ;  may  also  note,  if  possible,  the  location  and  con- 
dition of  the  ovaries,  which,  especially  in  posterior  displacements,  are 
liable  to  be  prolapsed  and  excessively  sensitive,  and  to  constitute, 
therefore,  a  most  intractable  complication.  The  index-finger  sweeps 
around  the  cervix  in  search  of  tender  places  which  may  be  the  result 
of  inflammation  or  the  expression  of  some  neurosis.  Above  all,  the 
digital  examination  requires  a  light,  gentle,  delicate  touch.  The 
index-finger  may  now  be  removed  and  reintroduced  into  the  rectum, 
the  right  hand  still  being  behind  the  pubes,  or  the  cervix  may  be 
grasped  between  the  index-finger  in  the  rectum  and  the  thumb  in 
the  vagina,  picked  up,  as  it  were,  between  the  finger  and  the  thumb 
thus  placed,  and  with  the  aid  of  the  right  hand  behind  the  pubes 
thoroughly  palpated. 

Adequate  diagnosis  of  the  position  of  the  pelvic  organs  usually  is 
made  by  touch  and  conjoined  palpation.  It  is  seldom  necessary  or 
desirable  to  sound  or  probe  the  uterine  cavity  in  order  to  learn  the 
position  of  the  uterus  ;  indeed,  accurate  information  in  the  majority 
of  cases  can  be  gained  more  readily  and  more  safely  by  touch  alone. 
A  tumor  or  inflammatory  mass  in  the  pelvis  may  be  confused  with 
the  uterus.     In  such  a  case  the  uterus  may  be  located  definitely — 


634  DISPLACEMENTS. 

relative  position  determined — by  the  sound  or  probe.  When  the 
uterine  canal  thus  is  explored,  the  patient  may  be  on  her  back,  and 
the  left  index-finger  in  the  vagina  may  be  used  as  a  guide.  The 
exploration,  however,  is  made  most  effectually  and  gently  with  Sims' 
speculum,  the  patient  being  in  the  left  lateroprone  position.  In  some 
cases  the  probe  cannot  be  passed  by  any  other  method.  The  bivalve 
and  cylindrical  specula  are  unsatisfactory  in  explorations  of  the  inte- 
rior of  the  uterus. 


CHAPTER    XLV. 

MAL-LOCATIONS    OF  THE   UTERUS. 

Ascent.    Retrolo cation.    Antelocation.    Lateral  Locations. 
Descent  or  Prolapse. 

ASCENT  OF  THE  UTERUS. 

Ascent  of  the  uterus  may  result  from  traction  above  or  pressure 
below.     The  organ  may  be  drawn  upward  and  backward  by  a  contrac- 

FiGURE  342. 


Schematic  drawing  of  various  mal-locations. 

tion  of  the  uterosacral  ligaments,  which  results  from  inflammation, 
and  which  usually  induces  a  troublesome  form  of  anteflexion.  The 
enlarged  pregnant  uterus  sometimes  becomes  attached  by  adhesive 
inflammation  to  a  portion  of  the  peritoneum  in  one  of  the  higher 
zones  of  the  pelvis  or  in  the  abdomen,  and  the  organ  may  remain 
consequently    fixed    in   its    elevated    position    after   involution.     A 

635 


636  DISPLACEMENTS. 


^ 


tumor  connected  with  the  uterus  or  its  appendages  which  has  grown 
too  large  to  be  retained  in  the  pelvis  may,  upon  rising  into  the  abdo- 
men, drag  the  uterus  with  it.  Pressure  below  may  come  from 
excessive  distention  of  the  rectum  or  bladder,  or  from  a  large  accu- 
mulation of  menstrual  fluid  in  the  vagina,  or  from  a  tumor  originat- 
ing in  any  portion  of  the  pelvis  below  the  level  of  the  uterus. 

RETROLOCATION  OF    THE   UTERUS. 

The  uterus  may  be  forced  back  into  a  post-normal  location  by  the 
presence  of  a  tumor  in  front  or  by  the  distended  bladder,  or  it  may  be 
drawn  back  and  fixed  by  peritoneal  adhesions,  Retrolocation  is 
liable  to  induce  vesical  irritation  by  putting  the  vesicovaginal  wall  on 
the  stretch,  and   thereby  dragging  on  the  neck  of  the  bladder. 

ANTELOCATION  OF  THE  UTERUS. 

The  causes  of  this  displacement  are  similar  to  those  which  produce 
retrolocation  ;  they  are  :  distention  of  the  rectum,  post-uterine 
hsematocele,  post-uterine  tumors,  contraction  of  the  bladder,  and  peri- 
toneal adhesions.  Antelocation  often  causes  vesical  irritation,  conse- 
quent upon  the  invasion  by  the  uterus  of  space  which  belongs  to  the 
bladder. 

LATERAL  LOCATION  OF  THE  UTERUS. 

The  entire  uterus  often  is  displaced  to  the  right  or  to  the  left  by 
a  tumor  or  by  an  inflammatory  mass.  In  either  case  the  uterus  is 
crowded  to  the  opposite  side  'of  the  pelvis.  After  resolution  of  an 
inflammatory  mass  the  broad  ligament  and  adjacent  inflamed  struct- 
ures, shortened  by  cicatricial  contraction,  draw  the  uterus  to  the 
afiected  side  and  fix  it  there.  Laceration  of  the  cervix  opens  the 
way  to  infection,  and  therefore  often  is  followed  by  inflammation  in 
the  parametrium  on  the  corresponding  side. 

Diagnosis,  Symptoms,  and    Treatment  of  Ascent,  Retrolocation, 
Antelocation,  and    Lateral  Location  of  the  Uterus. 

The  diagnosis,  symptoms,  and  treatment  of  the  above  mal-loca- 
tions  are  wholly  subordinate  to  the  more  significant  lesions  of  which 
they  are  only  the  incidental  results. 

The  Treatment  for  mal-locations  due  to  inflammatory  causes  is  the 
same  as  that  for  the  inflammation.  The  indications  for  topical  treat- 
ment and  surgical  measures,  including  operations  on  the  uterus  and 
Its  appendages  and  the  removal  of  tumors,  will  vary  with  the  causa- 
tive lesions.  In  many  cases  mal-locations  of  the  uterus  give  rise  to 
no  symptoms,  and  therefore  require  no  treatment.  Pessaries  for  all 
mal-locations  except  descent  are  useless,  and  may  be  harmful. 


MAL-LOCATIONS  OF  THE   UTERUS.  637 

DESCENT    OR    PROLAPSE  OF  THE  UTERUS. 

The  nature  of  this  displacement  is  indicated  clearly  by  the  name. 
It  is  convenient  to  distinguish  three  degrees  of  descent : 

First  Degree :  The  uterus  is  displaced  downward  until  sufficient 
space  has  been  gained  between  the  cervix  and  the  sacrum  to  permit  the 
corpus  to  turn  back  into  extreme  retroversion. 

Second  Degree  :  The  cervix  descends  to  the  vulva. 

Third  Degree  :  The  uterus  protrudes  partially  or  wholly  through  the 
vulva.     The  third  degree  of  descent  sometimes  is  called  procidentia. 

Etiology  and  Mechanism  of  Descent  of  the  Uterus. 

Descent  may  be  the  result  of  any  or  all  of  the  following  causes  :^     .     ,  , 

1.  Pressure  from  above.  '  (^   &Jv»^  TPCtAUj^  t^    ^*^ 

2.  Weakening  of  the  uterine  supports.  ^Sdt^eM  vK&*f    O/iXw    -j^^-^y^^Jut, 

3.  Increased  weight  of  the  uterus. 

4.  Traction  from  below. 

Any  of  the  above  conditions  being  the  primary  cause,  the  others 
singly  or  combined  may  result. 

1.  Pressure  from  Above. — Under  this  head  may  be  included  : 

g.^elvic  or  abdominal  tumors.         <^.-<^-m   <!yU-     iJr-'JA^— - 

b.  Ascites. 

c.  Tight  or  heavy  clothing. 

d.  Straining  at  stool. 

e.  Muscular  exertion. 
/.  Fecal  accumulations. 

g.  Habitual  overdistention  of  the  bladder. 

2.  Weakening  and  Relaxation  of  the  Uterine  Supports  may 

^.  Senile  atrophy  of  the  pelvic  floor.^^^j,   ^    p-^f^  fi^~g-^ 

c.  Abnormally  large  pelvis.  ^  . 

d.  Increa_sedjffi£ightof  the  uteru§.  ^ux^n^^-^jax^  Aj(tj^^  ''^ 

e.  Puerjjeral  traumatisms.  <3td2vvt>«-vxj.     S'i^^^ti^uMjJL  /t<X»>' 
/.  Pressure  from  above.  /   _#  «    »  % 

g.  Traction  from  below.  ^^^«^    "^    """^  d^^J^XiXT 

•^  3.  Increased  Weight  of  the  Uterus. — Among  the  pathological 
developments  which  cause  increased  weight  are : 

a.  Cong£slioij^  *^'*f'  fl     /    ^ 

6.  _SulMnvolution,      (^    s^    U>—    ;;  f-^-^^  ^^'^    ®^^*^  ^"^^^ ' 

c.  Metritis. 

d.  .Pregnane;^. 

e.  Fluid  in  the  endometrium. 

/.  TTtp-rinP  tumorg.      (^^a^^  -"C^   f^^^M.^- a**-^- 
4.  Traction  from  Below  may  be  due  to  such  causes  as  : 
a.  Vaginal  cicatrices. 
h.  Falling  of  the  pelvic  floor. 

c.  Contraction  and  congenital  shortening  of  the  vagina. 

d.  Tumors  of  the  cervix  or  vagina. 

*  Adapted  from  Thomas'  Diseases  of  Women. 
39  ■       .    . 


638 


BIS  PL  A  CEMENTS. 

Figure  343. 


'S'^ 


i-i 


/SaP^ 


Uterus  between  first  and  second  degrees  of  descent.    Rectocele  and  cystocele. 
Semi-diagrammatic. 

Figure  344. 


Second  degree  of  descent .    Cervix  appears  at  the  vulva.     Rectocele  and  cystocele, 
Semi-diagrammatic. 


MAL-LOGATIONS  OF  THE   UTERUS. 


639 


Complete  or  third  degree  of  descent.    Rectocele  and  cystocele.    Rectocele  forms  a  poach  in 
which  scybalse  may  accumulate.    Semi-diagrammatic. 


FiGrRE  346. 


4   ^M. 


A^    f 


J4~  <Se*'»*v 


Complete  or  third  degree  of  descent.  Vaginal  wall  peeled  off  from  the  rectum  leaving  the 
rectal  wall  in  normal  position.  Cystocele  extreme  ;  no  rectocele.  Semi-diagrammatic.  Bladder 
displaced  with  the  uterus. 


640  DISPLACEMENTS. 

Uterogestation,  parturition,  and  the  puerperium  may  be  followed 
by  increased  weight  of  the  uterus  and  weakening  of  the  suj^ports  from 
subinvolution.  Puerperal  traumatism  may  injure  the  vaginal  outlet 
and  cause  the  vaginal  walls  to  fall ;  these  in  turn  may  drag  the  uterus 
down  after  them ;  indeed,  excessive  descent  of  the  vaginal  walls 
usually  originates  in  parturition.  Obviously,  descent  of  the  vesicovaginal 
and  rectovaginal  v/alls,  or,  more  comprehensively,  the  sacral  and 
pubic  segments  of  the  pelvic  floor,  involves  also  concurrent  descent 
of  the  uterus  and  its  appendages.  It  is  clear  from  the  above  that 
descent  of  the  vagina  must  be  studied  in  connection  with  the  descent 
of  the  uterus. 

In  labor  the  anterior  wall  of  the  vagina  is  so  depressed,  stretched, 
and  shortened  by  the  advancing  head  of  the  child  that  during  and  after 
the  second  stage  the  anterior  lip  of  the  cervix  may  be  seen  behind  the 
urethra.  If  the  puerperium  progresses  favorably,  with  prompt  involu- 
tion of  the  uterus,  vagina,  perineum,  and  peritoneum,  the  relaxation 
of  the  vesicovaginal  wall  and  of  the  uterosacral  supports  disappears 
and  the  uterus  resumes  its  normal  multiparous  location  and  position. 
But  if  the  enlarged  uterus  remain  in  the  long  axis  of  the  vagina,  with 
its  fundus  incarcerated  in  the  hollow  of  the  sacrum  between  the  utero- 
sacral ligaments,  and  with  its  sacral  supports  stretched  for  so  long  a 
time  that  they  cannot  recover  their  contractile  power,  and  with  involu- 
tion of  all  the  pelvic  organs  arrested,  the  descent  may  not  only  persist, 
but  may  even  progress,  with  constantly  increasing  protrusion  of  the 
vesicovaginal  wall — cystocele — to  the  third  degree  of  prolapse.  The 
downward  influence  of  the  above  conditions  may  be  increased  mate- 
rially by  rupture  of  the  perineum  and  consequent  prolapse  of  the 
rectovaginal  wall  into  a  pouch,  called  rectocele. 

In  the  great  majority  of  cases  of  complete  prolapse  the  posterior 
vaginal  wall  in  its  descent  is  peeled  oif  from  the  rectum,  as  shown  in 
Figure  346,  leaving  the  latter  in  the  normal  position.  In  rare  instances 
the  lower  portion  of  the  rectum  also  is  found  to  have  extruded  in 
extreme  rectocele,  making  a  pouch  below  and  in  front  of  the  anus,  in 
which  fecal  matter  may  accumulate  and  remain  as  hard  scybalse. 
See  Figure  345. 

Obviously,  complete  prolapse  of  the  uterus  is  only  an  incident  to 
prolapse  of  the  pelvic  floor.  The  tvhole  mechanism  is  in  all  respects 
analogous  to  that  of  hernia.  The  extruded  hernial  mass  drags  after  it 
a  peritoneal  sac,  which,  hernia-like,  contains  small  intestine.  This  sac 
forces  its  way  to  the  pelvic  outlet  and  extrudes  through  the  vulva, 
having  the  inverted  vagina  for  a  covering. 

In  the  first  degree  of  descent,  Figure  354,  as  we  have  said,  the 
uterus  is  displaced  downM'ard  and  forward  sufficiently  to  permit  the 
body  to  turn  back  into  retroversion  ;  as  already  stated,  the  organ  in 
its  normal  location  cannot  retrovert,  because  in  so  doing  it  would 
impinge  upon  the  bony  sacrum.  As  a  consequence  of  the  first  degree 
of  descent  there  are  two  significant  possibilities  :  First,  as  the  uterus 
falls  to  a  lower  level,  where  it  would  crowd  upon  and  irritate  the 
bladder,  its  long  axis  usually  changes  so  as  more  and  more  to  conform 
to  that  of  the  vagina,  the  cervix  moves  toward  the  pubes,  and  the 


MAL-LOCATIONS   OF  TEE   UTERUS. 


641 


Figure  347. 


Figure  348. 


FiGfRE  347.— Descent  of  the  uterus  to  the  third  degree.  The  cervix  appears  at  the  vulva 
carrying  with  it  the  vesicovaginal  and  rectovaginal  walls :  tliat  is,  the  rectun:  and  bladder 
are  in  descent  together  with  the  uterus,  having  dragged  the  uterus  down  with  them. 

Figure  348. — Descent  of  the  uterus  to  the  third  degree.  The  cervix  appears  at  the  vulva, 
not  dragged  down  by  the  prolapsing  rectum  and  vagina,  but  dragging  them  down  after  it,  as 
shown  in  section  in  Figure  351. 


Figure  349. 


Figure  350. 


Figure  349.— Complete  descent  of  the  uterus,  vagina,  and  bladder  with  ulceration  of  ex- 
posed surfaces.  The  os  externum  is  at  the  bottom  of  the  picture.  That  portion  of  the  sound 
which  is  in  the  bladder  is  shown  by  dotted  lines. 

Figure  350.— Complete  descent  of  the  retrofiexed  uterus:  the  cervix  and  external  os  uteri 
show  in  the  upper  part  of  the  prolapsed  structures  and  the  corpus  uteri  in  the  lower  part. 


642 


DISPLA  CEMENTS. 


corpus  toward  the  sacrum — that  is,  it  turns  back  away  from  the  blad- 
der into  retroversion  ;  this  is  as  if  the  irritated  bladder,  in  the  pro- 
tection of  its  own  rights  and  territory,  had  thrown  the  uterus  back ; 
second,  instead  of  turning  back  into  retroversion,  the  uterus  simply 
may  change  its  location  to  a  lower  level,  while  the  position  remains 
the  same — that  is,  the  organ,  still  retaining  its  normal  position  of  ante- 
version  and  anteflexion,  only  may  settle  to  a  lower  plane.  It  must 
then  occupy  space  that  belongs  to  the  bladder.  The  normally  ante- 
verted  and  anteflexed  uterus  in  such  descent  is  much  more  palpable 


Figure  351. 


Figure  352. 


Figure  351.— Descent  of  the  virgin  uterus  into  the  vaginal  canal,  showing  reduplicated 
vaginal  walls.  The  uterovaginal  attachment,  points  Xand  Z,  appears  to  be  at  A"  and  Z'.  The 
apparent  increase  of  length  in  the  vaginal  portion  of  the  cervix,  due  to  the  reduplication,  is 
measured  by  the  distance  from  A" and  Z  to  X'  and  Z' . 

Figure  352.— Descent  of  the  uterus,  showing  excessive  circular  enlargement  of  the  lacerated 
cervix,  consequent  upon  reduplication  of  the  vaginal  walls  and  outroUing  of  intracervical 
tissues.  The  divided  fragments  of  the  os  externum  are  at  a  and  b.  The  curved  lines  forming 
the  angles  1,  2.,  3,  and  4  indicate  the  gradual  process  of  eversion.  The  angle  of  the  lacera- 
tion originally  at  point  1  has  been  forced  down  by  the  swelling  and  outrolling  of  the  mucous 
and  submucous  tissues  of  the  cervix  to  point  4.  The  apparent  os  externum  is  at  point  4.  The 
uterovaginal  attachment  A' and  Z  seems  to  be  at  X'  and  Z'.  The  vaginal  portion  of  the  cervix 
therefore  appears  much  larger  and  longer  than  it  actually  is.  This  is  rather  descent  by  outroll- 
ing of  the  cervical  mucosa  rather  than  of  the  entire  uterus. 


to  digital  examination,  and  for  this  reason  the  vesical  irritation  conse- 
quent upon  the  descent  often  has  been  attributed  wrongly  to  the 
anteversion  and  anteflexion.  In  this  way  has  arisen  much  confusion 
in  the  efibrt^  to  draw  the  line  between  normal  and  pathological 
anterior  positions.  The  prompt  relief  which  follows  permanent  re- 
placement of  the  organ  to  the  normal  location,  even  though  in  so 
doing  the  anteposition  be  exaggerated,  proves  that  the  symptoms 
depend  upon  the  mal-location,  not  upon  the  anteposition.  The  im- 
portance of  a  clear  distinction  therefore  between  location  and  position 
becomes  apparent. 


MAL-LOCATIONS  OF  THE   UTERUS.  643 

Another  cause  of  vesical  irritation  is  the  dragging  of  the  uterus 
upon  the  neck  of  the  bladder.  This  traction  occurs  not  only  in 
ascent,  but  also  when  the  organ  descends  below  a  certain  level. 

In  the  foregoing  paragraphs  traction  due  to  the  falling  pelvic 
floor  has  been  discussed  as  a  cause  of  descent.  Impairment  of  the 
uterine  supports  may,  however,  be  such  that,  instead  of  falling  and 
dragging  the  uterus  after  them,  they  simply  permit  it  to  descend 
along  the  vaginal  canal  by  the  force  of  its  own  weight,  and  to  carry 
with  it  the  reduplicated  vaginal  Avails.  This  influence  is  enforced 
generally  by  increased  weight  of  the  diseased  organ.  The  vagina 
more  readily  becomes  a  track  for  the  descending  uterus  when  from 
any  cause  the  normal  forward  direction  of  the  vaginal  canal  changes 
toward  the  vertical ;  this  change  in  the  direction  of  the  vagina  may 
occur  either  as  the  result  of  forward  displacement  of  its  upper  ex- 
tremity or  of  retrodisplacement  of  its  lower  extremity.  The  former 
involves  anteposition  of  the  cervix ;  the  latter,  backward  displacement 
of  the  perineum.  For  a  full  discussion  of  backward  displacement  of 
the  lower  part  of  the  vagina  and  vulva  toward  the  coccyx,  see  Lacer- 
ation of  the  Perineum  and  Injuries  of  the  Pelvic  Floor,  in  Chapters 
XL.  and  XLI.  When  the  uterus  descends  along  the  track  of  the 
vagina,  the  long  axes  of  the  two  organs  will  correspond  ;  hence,  such 
descent  must  involve  a  degree  of  retroversion.     See  Figure  354. 

Pathology  of  Descent  of  the  Uterus. 

The  pathology  may  involve  all  the  displaced  organs.  The  circu- 
lation throughout  the  pelvis  is  impeded  by  traction  upon  the  vessels ; 
the  entire  pelvic  contents  therefore  become  the  subject  of  venous  con- 
gestion, with  consequences  disastrous  to  local  innervation  and  nutri- 
tion. The  ovaries  and  Fallopian  tubes  suffer  concurrent  displace- 
ment. That  portion  of  the  peritoneum  which  enters  into  the  formation 
of  the  uterine  ligaments  and  of  the  pelvic  floor  is  dragged  along  with 
the  uterus.  The  vagina,  also  displaced,  may  become  hypertrophied, 
swollen,  and  inflamed. 

Sometimes  the  cul-de-sac  of  Douglas  is  distended  by  downward 
pressure  of  the  intestine,  by  a  small  tumor,  or  by  ascitic  fluid,  and 
a  consequent  hernial  sac  may  protrude  into  the  vagina  through  some 
portion  of  the  posterior  vaginal  fornix.  The  anterior  fornix  is  subject 
to  a  similar  accident.  These  conditions  are  designated  enter ocele 
vaginalis  anterior  and  posterior. 

In  the  third  degree  of  descent  the  vagina,  now  rolled  out  and  ex- 
posed to  external  conditions,  is  no  longer  lubricated  and  protected  by 
normal  secretions,  and  therefore  becomes  dry,  parchment-like,  oedema- 
tous,  eroded,  and  perhaps  ulcerated. 

The  rectum  and  bladder  are  subject  to  infection  and  chronic  catarrh, 
and  to  concurrent  descent.  The  uterus  may  be  enlarged  from  any  one 
or  all  of  a  variety  of  causes :  congestion,  subinvolution,  hypertrophy, 
and  hyperplasia.  The  cervix  is  often  the  seat  of  extreme  erosion  or 
ulceration.  The  endometrium,  in  order  to  relieve  the  organ  of  surplus 
blood,  gives   forth   an   excessive   secretion   of  vitiated  mucus   from 


644 


D  ISP  LA  CEMENTS. 


uterine  catarrh.  The  enlargement  of  the  uterus,  if  the  cervix  is 
lacerated,  often  pertains  more  to  the  cervix  than  to  the  body,  espe- 
cially in  prolapse  of  the  second  and  third  degrees.  An  explanation 
of  this  may  be  found  in  Figures  351  and  352. 

Apparent  elongation  and  disproportionate  circular  enlargement  of 
the  cervix  are  conditions  which  many  standard  authors  wrongly  call 
hypertrophic  elongation  and  circular  hypertrophy.  The  question  of 
infravaginal  elongation  is  easily  settled  by  placing  the  patient  in  the 
knee-breast  position.  Then  the  uterus,  by  its  own  weight,  falls  toward 
the  diaphragm,  the  reduplicated  vagina  unfolds,  and  the  apparent 
uterovaginal   attachment,  X'Z',    Figures    351    and    352,  disappears, 

Figure  353. 


This  cut  is  from  a  part  of  an  illustration  in  a  standard  text-book.  It  is  reproduced  to  illus- 
trate the  current  misconception  of  complete  prolapse  and  apparent  elongation  of  the  cervix. 
The  apparent  elongation  almost  invariably  disappears  on  replacement  of  the  uterus.  The  ap- 
pearance of  elongation  is  due  to  congestion  and  vaginal  reduplication.  Amputation  of  such  a 
cervix,  so  often  advised,  would  be  apt  to  involve  the  bladder  in  front  and  the  cul-de-sac  of 
Douglas  behind.  Actual  elongation  of  the  cervix  has  seldom  been  demonstrated  satisfactorily. 
Elongation,  if  present  at  all,  is  almost  always  at  least  in  the  supravaginal,  not  the  infravaginal 
portion  of  the  cervix.  The  uterovaginal  attachment  cannot  be  therefore  as  indicated  at  ZZ; 
It  is  on  a  plane  slightly  above  XX 

disclosing  the  actual  attachment,  XZ.  Further,  the  point  of  the 
sound,  passed  into  the  bladder  while  the  cervix  is  exposed  by  Sims' 
speculum,  may  be  placed  against  the  anterior  wall  of  the  cervix  at  Z, 
which  would  be  impossiblelf  the  attachment  were  at  Z'. 

The  comparatively  small  amount  of  hypertrophy  in  disproportion- 
ate circular  enlargement  due  to  an  associated  laceration  of  the  cervix 
uteri,  is  proved  by  the  operation  of  trachelorrhaphy  or  by  rolling  in 
the  outrolled  tissues  with  uterine  tenacula,  as  shown  in  Figure  307. 
When  the  outrolled  intracervical  mucous  tissues  are  rolled  in,  the 
proper  diameter  of  the  cervix  is  restored,  and  a  laceration  on  one  or 
both  sides,  extending  past  the  vaginal  attachment,  becomes  apparent. 


MAL-LOCATIONS  OF  THE   UTERUS.  645 

Those  cases  in  which  reduplication  of  the  vaginal  walls  does  not 
almost  entirely  explain  the  great  elongation  so-called,  or  in  which 
great  disproportionate  circular  enlargement  has  not  been  caused  by 
an  associated  laceration  of  the  cervix,  are  the  rare  exceptions.  For- 
merly these  mechanical  conditions  were  attributed  to  hypertrophic 
changes,  and  were  regarded  as  adequate  indications  fgr  removal  of 
the  cervix.  Such  elongation  as  is  shown  in  Figures  300  and  353 
rarely,  if  ever,  exists.  Emmet,  with  his  enormous  experience,  has 
never  seen  such  a  ease,  and  denies  its  existence.  Congestion  of  the 
prolapsed  uterus  consequent  upon  obstruction  in  the  stretched  and 
displaced  veins  is  often  so  extreme  as  to  induce  a  state  analogous  to 
erection.  Measurements  by  the  probe  just  before  and  a  few  minutes 
after  replacement  generally  show  a  very  appreciable  decrease  in  the 
length  of  the  uterine  canal.  If  the  prolapse  has  been  of  the  third 
degree,  the  difference  may  amount  to  one  or  even  two  inches.  It  is 
clearly  important  not  to  confound  the  enlargement  of  congestion  with 
increase  in  the  solid  constituents  of  the  organ.  See  Laceration  of  the 
Cervix.  The  great  merit  of  having  secured  general  assent  to  the 
foregoing  propositions,  and  of  having  given  to  the  subject  a  new 
and  right  direction,  must  be  accorded  to  Emmet.  The  cervix  now 
seldom  is  amputated  for  so-called  Hypertrophy. 

Symptoms  and  Course  of  Descent  of  the  Uterus. 

The  course  of  descent  is  ordinarily  chronic,  but  intercurrent  attacks 
of  acute  vaginitis  are  rather  common.     Peritonitis  sometimes  effects  a 
spontaneous  cure  by  peritoneal   adhesions  that  fasten  the  uterus  in  an 
elevated  position  and  hold  it  permanently.     The  symptoms  of  descent 
may  be  so  severe  as  to  necessitate  for  the  patient  absolute  rest  in  bed, 
or  they  may  be  attended  with  very  little  discomfort ;  the  usual  symp- 
toms are  these :  ^  -  ^    t,  ^  ^  v 
1.  AbdominaLpains.       ^^'^^^  (S.r>-^  ^ioh^  h--     d^M-— ^ 
^                        2.  Dragging  paina_in  the  pelvis  extending  to  the  thighs. 
I^tad^k^          3.  Functional  disturbances  of the_bl^5^erand  rectum — tenesmus. wjfe^^ 
^f****^  (f*^*^         4.  In  cases  of  complete  prolapse  ;  sutternigfrom  excoriation  or  ** 
ulceration  of  the  exposed  vagina  or  cervix  uteri. 

5.  Great  irritation  from  vaginitis  and  pain  from  possible  peri- 

tonitis. 

6.  Uterine   hemorrhages   and    other   menstrual   disordegg — fre- 

quent.     <?r    -t<^er'e:-<*Tui-«>     sj^..i.aJU^  . 

7.  Leucorrhoea.  • 

8.  Sterility.    -OJ^yCu^   *^,^^  ''^'^***   ^-t^. 

Diagnosis  and  Differential  Diagnosis  of  Descent  of  the  Uterus. 

The  diagnosis  is  by  inspection,  palpation,  and  exploration.  The 
prolapsed  uterus  may  be  distinguished  from  cystocele,  rectocele,  in- 
verted uterus,  vaginal  cysts,  and  fibroid  tumor  by  the  presence  of  the 
OS  externum.  The  length  of  the  uterus  may  be  measured  by  the 
sound ;  the  size,  shape,  position,  extent  of  descent,  and  difficulty  of 
replacement  may  be  determined  by  conjoined  manipulation. 


646  DISPLACEMENTS. 

Diagnosis  of  Associated  Cystocele  and  Eectocele. 

fi^blr€4     Cystocelema^.be^ecognized..bjr —  , 

/^ '  ^  "SrXconvex  protrusion  between  the  labia  covered  with  rugous 

rU'     liAU  '         vaginal  mucosa,  easily  pushed  back,  and  diminishing  when 

kyjy^JU^  *^^  patient  lies  down. 

^    I         f         6.  A  sound  in  the  bladder  may  be  felt  by  the  finger  against  the 
Q^,^,^u^>  protrusion,   thereby    demonstrating   it   to    be  continuous 

^^^  ^yjl-}^  ^|-,Q  vesicovaginal  wall  and  formed  of  it. 

c.   After  urination  there  will  remain   residual  urine  in  the  pro- 
truding sac.     This  often  causes  cystitis  and  stone  in  the 
bladder. 
Eectocele  may  be  recognized  by — 

«.  Bulging  forward  of  the  posterior  vaginal  wall,  the  protruding 

mass  being  covered  with  rugous  vaginal  mucosa. 
h.  Mass  increasing  in  size  on  straining  at  stool  and  diminishing 
on  lying  down. 

c.  Finger  in  the  rectum,  wdiich  enters   the  protruding  mass,  and 

demonstrates  it  to  be  continuous  with  the  rectovaginal 
septum  and  composed  of  it. 

d.  Lodgement  of    feces  in  the  pouch  and  prevention  of  com- 

plete  emptying  of  the  bowel ;    it    may  be  necessary  to 
facilitate  defecation  by  pushing  the  pouch  back  with  the 
finger. 
Cystocele  and  rectocele  are  apt  to  be  associated  with  intermittent 

accumulations  of  air  in  the  vagina,  which  may  be  expelled  with  a 

peculiar  sound — so-called  garrulity  of  the  vulva. 

Prophylaxis  of  Descent  of  the  Uterus. 

Prophylaxis  requires  such  measures  during  labor  as  will  prevent 
long  and  powerful  pressure  upon  the  pelvic  floor.  After  labor  any 
injury  to  the  perineum  should  be  repaired  promptly.  The  vagina 
should  be  kept  clean  by  irrigations.  The  urine,  if  retained,  should  be 
drawn  regularly  and  the  bowels  moved  daily  without  straining.  If 
conditions  be  present  likely  to  induce  subinvolution,  such,  for  example, 
as  pelvic  infection  and  laceration  of  the  cervix,  they  should  receive 
treatment  at  the  proper  time.  Undue  relaxation  of  the  pelvic  floor 
necessitates  prolonged  rest  in  bed,  the  use  of  astringent  douches, 
and,  when  the  patient  resumes  the  upright  position,  the  application  of 
a  pessary.  If  involution  goes  on  with  the  uterus  congested  and  irri- 
tated by  descent,  the  result  is  apt  to  be  perpetuation  of  the  displace- 
ment and  its  attendant  evils ;  it  is  therefore  highly  desirable  that  the 
uterus  be  kept  in  place  during  the  puerperium  ;  to  this  end,  even 
while  the  patient  is  in  bed,  a  pessary  may  be  indicated.  The  great 
prophylactic  value  of  rest  in  bed,  prolonged  for  seven  or  eight  weeks 
after  labor,  is  undeniable.  The  puerpenum  offers  the  best  conditions 
for  the  prophylaxis  and  cure  of  descent. 


MAL-LOCATIONS  OF  THE   UTERUS.  647 

Treatment  of  Descent  of  the  Uterus. 
Treatment  may  be  surgical  or  non-surgical. 

Non-surgical  Treatment. 

Replacement. — The  first  indication  is  replacement,  which,  in  the 
first  and  second  degrees  of  descent,  is  not  difficult  unless  the  uterus  is 
held  down  by  cicatrices  or  by  a  tumor.  Acute  pelvic  inflammation 
may  render  replacement  dangerous  or  impossible,  and  may  for  a  time 
contraiudicate  all  direct  treatment.  Replacement  of  the  organs  from 
the  third  degree  of  prolapse  is  accomplished  in  the  inverse  order  of 
their  descent :  first,  the  posterior  vaginal  wall,  then  the  uterus,  and 
lastly  the  anterior  vaginal  wall.  Xot  infrequently  the  completely  pro- 
lapsed uterus  and  pelvic  floor,  hernia-like,  become  strangulated.  Then 
taxis  usually  will  suffice  ;  but  it  may  have  to  be  supplemented  by  hot 
applications,  elastic  pressure,  anodynes,  and  the  knee-breast  position, 
and,  should  these  fail,  anaesthesia. 

In  exceptional  cases  of  sudden  descent,  even  to  the  third  degree, 
replacement  alone  is  followed  sometimes  by  permanent  relief ;  but  if 
the  descent  has  been  gradual,  it  always  occurs  immediately  after 
replacement.  Measures  are  required  therefore  for  the  maintenance 
of  the  uterus  in  the  normal  location  and  position.  This  indication  is 
fulfilled  by : 

Hygiene.  Pessaries. 

General  and  local  measures.  Surgical  operations. 

The  Hygiene  principally  relates  to  dress,  food,  exercise,  and  regular 
habit  of  the  bowels.  Undue  pressure  from  above  should,  if  possible, 
be  avoided.  The  clothing  should  be  loose,  and  the  weight  of  the 
skirts  supported  from  the  shoulders  either  by  straps  or,  preferably,  by 
buttoning  them  upon  a  waist  made  for  the  purpose.  The  waist  is  a 
good  substitute  for  the  corset,  which,  under  all  circumstances  and  in 
all  forms,  is  injurious.  Constipation  and  the  accumulation  of  feces  in 
the  lower  bowel  mechanically  irritate  and  may  displace  the  pelvic 
organs ;  straining  at  stool  exerts  a  strong  downward  pressm'e  on  the 
uterus  and  its  appendages.  Careful  regulation  of  the  bowels  is 
therefore  imperative ;  to  this  purpose  food  and  exercise  are  the  most 
essential  agents. 

General  and  Local  Measures. — The  value  of  general  massage  for 
women  unable  to  take  active  exercise  is  very  great.  As  a  supplement 
to  massage,  or  as  an  independent  measure,  one  may  urge  strongly  the 
knee-breast  position.  This  position  assumed  several  times  a  day 
causes  the  uterus  to  gravitate  toward  the  diaphragm,  and  thereby  gives 
temporary  rest  to  the  overburdened  supports.  AVhile  in  this  position- 
the  patient  should  separate  the  labia  so  that  the  air  may  rush  in  and 
the  vagina  become  expanded.  Mineral  Maters  and  general  tonics  are 
useful.  The  measures  enumerated  above,  together  with  such  topical 
treatment  as  local  conditions  may  demand,  are  essential  as  adjuvants 
to  the  mechanical  or  surgical  treatment  which  almost  everv^  case 
requires. 


648  DISPLACEMENTS. 

Pessaries. — In  the  genesis  of  retroversion  and  retroflexion  the 
first  change  is  descent ;  hence,  the  principles  of  mechanical  treatment 
must  be  substantially  the  same  for  each.  The  reader  therefore  is 
referred  to  the  indications,  the  contraindications,  modes  of  adjust- 
ment, and  uses  of  pessaries  in  the  treatment  of  retroversion  and  retro- 
flexion. 

In  complete  prolapse  dependent  upon  extensive  injury  of  the 
perineum  and  other  parts  of  the  pelvic  floor,  and  associated  with  sub- 
involution and  relaxation  of  all  the  pelvic  organs,  the  axis  of  the 
vagina  is  changed  from  its  forward  oblique  to  the  vertical  direction. 
See  Figure  354.  The  downward  traction  of  the  prolapsing  cystocele 
and  rectocele  upon  the  fornix  of  the  vagina  may  then  be  so  great  that 
the  pessary  is  inadequate  to  maintain  in  place  the  upper  extremity  of 
the  vagina.  The  cervix  uteri  then  moves  forward,  the  corpus  turns 
back,  and  the  whole  uterus  easily  descends  in  a  vertical  direction 
along  the  prolapsing  walls  of  the  vagina  to  the  second  or  third  degree 
of  prolapse.  In  this  condition  pessaries  that  disappear  within  the 
vagina  are  liable  to  be  forced  out  with  the  prolapsing  pelvic  floor,  or, 
if  retained,  seldom  maintain  the  uterus  in  position.  In  such  cases  the 
various  cup  pessaries,  that  are  supplied  with  external  attachments  and 
abdominal  belts,  often  are  used  ;  but  they  either  so  fix  the  uterus  as 
to  prevent  its  normal  movements,  or  hold  it  in  such  unstable  equi- 
librium that  it  may  assume  any  one  of  the  various  malpositions — 
anterior,  posterior,  or  lateral ;  they  are  open  to  the  further  serious 
objection  of  constantly  reminding  the  patient  of  their  presence,  and 
for  these  reasons  are  not  generally  approved  ;  they  are,  however, 
permissible  in  cases  of  complete  prolapse  when  the  patient  refuses 
surgical  relief.  As  an  expedient,  the  uterus  sometimes  may  be  held 
within  the  pelvis  by  means  of  a  large  Albert  Smith  pessary,  with  ex- 
treme uterine  and  pubic  curves  ;  see  Application  of  Pessaries  in  the 
Treatment  of  Retroversion. 


EXPLAJSTATION    OF   FiGUEE   354. 

A.  Incisions  have  been  made  from  the  posterior  vaginal  fornix  to  the  cul-de-sac  of 
Douglas  and  from  the  anterior  vaginal  fornix  to  the  utero-vesical  cul-de-sac.  The 
uterine  and  ovarian  arteries  in  both  ligaments  have  been  securely  ligated.  The  left 
ligament  has  been  cut  away  from  the  uterus  and  is  drawn  to  the  vulva  and  held  by 
forceps.  The  uterus  has  been  drawn  through  the  vulva  and  is  hanging  by  a  shred  to 
the  right  ligament,  from  which  it  is  being  cut  away.  The  wound  made  by  the  removal 
of  the  uterus  with  its  peritoneal  and  vaginal  margins  shows  between  the  ligaments. 

B.  The  last  stitch  of  a  continuous  catgut  suture  is  being  taken  to  unite  the  perito- 
neal margins  of  the  wound.  The  line  of  suture  thus  made  runs  from  one  ligament  to 
the  other  and  at  either  end  includes  the  ligament.  Closure  of  the  peritoneum  as  here 
shown  is  nearly  complete. 

C.  The  ends  of  the  broad  ligament  are  shown  to  be  united  in  front  of  the  perito- 
neum by  means  of  a  continuous  catgut  suture.  Another  suture  is  closing  the  vaginal 
margins  of  the  wound  by  a  line  of  union  running  across  the  upper  end  of  the  vagina 
from  side  to  side.  When  this  suture  is  complete,  the  united  broad  ligaments  will  lie 
between  peritoneum  and  vaginal  wall,  and  must  necessarily  sustain  the  rectum,  vagina, 
and  bladder  on  the  health  level. 


MAL-LOCATIONS  OF  THE   UTERUS. 

Figure  354. 


649 


650  DISPLACEMENTS. 

Surgical  Treatment. 

The  surgical  treatment  may  be  removal  of  the  uterus  by  hysterec- 
tomy, or  the  retention  of  it  in  its  normal  position  and  location  by 
means  of  plastic  operations. 

Hysterectomy. — The  failure  of  the  older  plastic  operations  to  hold 
the  uterus  in  place  permanently  has  induced  many  surgeons  to  adopt 
the  more  radical  operation  of  vaginal  hysterectomy — a  permissible 
operation  on  women  who  have  passed  the  menopause,  but  usually  not 
permissible  during  the  child-bearing  period.  Cases  are  numerous  in 
which,  after  vaginal  hysterectomy,  the  pelvic  floor,  and  with  it  the 
rectum,  vagina,  and  bladder,  have  protruded  again  through  the  vulva. 
For  this  reason  the  operation  always  shoukl  include  anchorage  of  the 
upper  end  of  the  vagina  to  its  normal  location  by  eud-to-eud  approxi- 
mation of  the  severed  broad  ligaments  in  the  wound  made  by  the 
removal  of  the  uterus.     See  Figure  354. 

Plastic  Operations. — The  rational  treatment  for  complete  prolapse 
requires  :  first,  an  operation  on  the  anterior  vaginal  wall  to  restore  the 
fornix  of  the  vagina  and  with  it  the  attached  cervix  to  their  normal 
place  in  the  hollow  of  the  sacrum  ;  second,  an  operation  at  the  vag- 
inal outlet  to  Ijring  the  posterior  vaginal  wall  well  in  contact  with 
the  anterior  and  thereby  to  restore  the  lower  extremity  of  the 
vagina,  together  with  the  perineum,  to  its  normal  place  under  the 
pubis.  The  numerous  plastic  operations  on  the  anterovaginal  wall 
for  the  relief  of  complete  descent  of  the  uterus  are  divisible  into  two 
classes  : 

1.  Narrowing  the  Vagina. 

2.  Changing  the  Direction  of  the  Vagina. 

1.  Ojyeratioiis  designed  to  hold  the  uterus  up  by  narrowing  the  vagina 
so  much  that  the  uterus  cannot  pass  through  it,  and,  consequently,  must 
be  raaintained  somewhere  in  the  pelvis  above  the  vaginal  constriction, 
usually  consist  in  the  removal  of  an  elliptical  piece  from  the  anterior 
or  posterior  wall  of  the  vagina,  or  from  both ;  or  of  making  longitud- 
inal denudations  and  bringing  the  edges  of  the  exposed  surfaces 
together  from  side  to  side.  In  this  class  of  operations  no  effort  is 
made  to  restore  the  normal  axes  of  the  uterus  or  the  vagina.  The 
whole  purpose  is  to  make  the  vagina  so  narrow  that  the  uterus  cannot 
pass  through  it.  Operations  of  this  class  generally  fail,  because  they 
do  not  restore  the  normal  angle  between  the  uterus  and  the  vagina. 
The  constricted  vagina,  indicated  by  the  white  lines  in  Figure  355, 
cannot  resist  the  downward  force  of  the  uterus,  which  almost  invari- 
ably dilates  the  vagina  a  second  time,  forces  itself  through,  and  repro- 
duces the  hernia.  Moreover,  the  operation  does  permanent  harm, 
because  it  shortens  the  vagina,  thereby  making  it  draw  the  cervix 
away  from  the  sacrum  toward  the  pubes.  This  forward  movement  of 
the  cervix,  as  already  stated,  is  an  element  in  the  genesis  of  descent, 
and  therefore  should  not  be  employed  in  the  treatment  of  it. 

2.  Operations  designed  to  hold  the  tderus  in  position  by  restoring  the 
normal  angle  beticeen  the  long  axis  of  the  tderus  and  the  long  axis  of  the 
vagina  may  narrow  somewhat  the  vagina,  but  such  narromng  is  only 


MAL-LOCATIONS  OF  THE   UTERUS. 


651 


an  incident  rather  to  be  regretted  than  desired.     It  is  not  essential  to 
the  success  of  the  operation. 

There  are  two  rational  indications  :  first,  to  fix  the  upper  extremity 
of  the  vagina  together  with  the  cervix  uteri  in  its  normal  location 
within  an  inch  of  the  junction  of  the  second  and  third  sacral  verte- 
brae, just  where  the  uterosacral  ligaments  would  hold  it  if  their  nor- 
mal tonicity  and  integrity  could  be  restored  ;  second,  to  bring  the 
lower  extremity  of  the  vagina  forward,  so  that  its  posterior  wall  shall 
be  close  up  against  the  pubes.  The  fulfilment  of  these  two  indica- 
tions will  restore  the  normal  obliquity  to  the  vagina,  and  will  hold 
the  cervix  so  far  back  toward  the  sacrum  that  the  corpus  uteri  cannot 

FlGIERE  355. 


Uterus  in  line  with  the  vagina;  first  degree  of  descent.    The  white  lines  in  the  vagina  show 
where  it  would  be  narrowed  by  the  first  class  of  operations. 

retrovert  or  prolapse,  but  must  be  directed  forward  in  its  normal 
anteverted  position  of  mobile  equilibrium.  In  this  wav  the  long  axis 
of  the  uterus  and  the  long  axis  of  the  vagina  will  form  an  "acute 
angle.  The  indications  are  fulfilled  best  by'elytrorrhaphy,  including 
end-to-end  approximation  of  the  cut  ends  of  the  broad  ligaments,  and 
perineorrhaphy. 

Eeynolds  wisely  says  :  "  The  first  point  is — that  to  attain  success 
we  should  ascertain  and  utilize  the  natural  supports  of  the  ante- 
rior wall  instead  of  simply  denuding  and  gathering  together  the 
overstretched  portions.  The  second,  that  we  should  not  only  avoid 
using  any  part  of  the  overstretched  portion  of  the  wall,  but'  should 


652  DISPLACEMENTS. 

actually  excise  and  do  away  with  it ;  both  of  which  objects  should 
be  attained  without  the  performance  of  an  unnecessarily  extensive  or 
severe  operation." 

"  The  mechanics  of  pelvic  support  are  after  many  years  still  the 
subject  of  dispute,  but  a  few  points  are  clear.  The  anterior  vaginal 
wall  has  naturally  two  fixed  points  of  attachment.  The  first  is  that 
of  the  lower  end  of  the  Avail  to  the  posterior  surface  of  the  pubes. 
This  is  exceedingly  firm  and  never  yields.  The  same  cannot  be  said 
of  the  attachments  of  the  upper  end  of  the  w^all ;  they  are,  however, 
sufficient  for  the  purpose.  In  prolapse  complicated  by  cystocele,  the 
correction  of  the  cystocele  is  essential  to  the  cure  of  the  prola]:)se. 
Our  experience  of  late  years  in  total  extirpation  of  the  uterus  has 
taught  us  that  the  only  attachment  between  the  genital  canal  and 
the  pelvic  wall,  which  is  not  readily  separated  with  the  finger,  is 
the  insertion  of  the  broad  ligaments  into  the  lateral  edges  of  the 
uterus  and  the  vault  of  the  vagina.  These  the  only  firm  supports  of 
the  vaginal  vault  furnish,  then,  the  only  upper  points  which  ration- 
ally can  be  used  in  the  restoration  of  the  anterior  wall.  The  utiliz- 
ation of  the  bases  of  the  broad  ligaments  has,  moreover,  the  very 
great  incidental  advantage  that  it  not  only  relieves  the  uterus  of  the 
weight  of  the  prolapsed  anterior  wall,  but  in  itself,  as  wall  be  seen, 
tends  to  restore  the  prolapse  by  throwing  the  cervix  backward.  The 
first  point  in  any  operation  then  should  be  the  attachment  to  each 
other  of  these  two  firm  portions  of  the  wall."  . 

The  fact  that  vaginal  hysterectomy  commonly  results  in  holding 
up  the  pelvic  floor,  and  with  it  the  rectum,  vagina,  and  bladder^  is 
because  in  this  operation  the  broad  ligaments  usually  are  fixed  in  the 
vaginal  wound ;  hence  the  same  result  may  be  secured  by  similar 
means,  even  though  the  uterus  is  not  removed.  Reynolds  further 
remarks  somewhat  as  follows  : 

''  To  this  first  principle  of  utilization  of  the  broad  ligaments  should 
be  added  the  second  principle  of  excision  of  the  weakened  portion  of  the 
anterior  vaginal  wall.  The  wall  in  its  natural  condition  is  a  short,  firm, 
fascial  and  muscular  structure,  which  extends  from  its  origin  at  the  firm 
bases  of  the  broad  ligaments  to  its  still  firmer  pubic  attachment,  thus 
forming  one  of  the  strongest  supports  of  the  uterus  and  other  pel- 
vic organs.  Look  now  at  its  condition  in  cystocele.  If  anyone  will 
freely  excise  the  anterior  wall  in  a  well-developed  cystocele,  he  will 
find  that  the  condition  is  that  represented  by  Figure  356,  neglecting 
the  diagrammatic  straight  lines — i.  e.,  that  the  central  portion  of  the 
protrusion  has  been  covered  by  an  overstretched,  thinned,  and  weak- 
ened vaginal  wall.  This  thin  portion  of  the  wall  is  overstretched 
because  it  has  lost  its  elasticity,  has  lost  its  powder  of  resistance  to 
further  stretching.  If  now  we  utilize  for  repair  any  part  of  this 
weakened  wall,  we  shall  have,  as  a  result,  a  weak  scar,  which  is 
necessarily  predisposed  to  further  stretching." 

"  Cystocele  is  in  effect  hernia  of  the  bladder  through  the  muscular 
and  fascial  structures  of  the  anterior  wall  of  the  vagina ;  hence  the 
second  principle  involved  in  dealing  wdth  it  is  essentially  that  which 
already  is  well  established  in  the  treatment  of  other  hernias.     It  has 


MAL-LOCATIONS  OF  THE   UTERUS. 


653 


been  customary  to  treat  cystocele  by  denuding  the  vaginal  wall  of  its 
epithelium,  invaginating  "the  protrusion,  and  stretching  the  denuded 
surfaces  together.  No  one  to-day  would  think  of  treating  any  other 
hernia  in  such  a  manner.  On  the  contrary,  we  are  accustomed  to 
treat  other  hernias  by  reducing  them  and  excising  the  sac  until  we 
lay  bare  strong,  firmly  attached  fascial  edges."  Such  should  be  the 
treatment  of  cystocele.  The  principle  as  set  fortli  by  Eeynolds  in  the 
above  quotation  has  led  me  to  abandon  my  previous  operations  for 
elytrorrhaphy  and  to  substitute  the  operation  about  to  be  described. 

FiGUEE  356. 


The  line  XY  shows  the  direction  and  location  of  the  vesicovaginal  wall  to  be  restored. 
The  light  radiating  lines  at  X  suggest  the  lines  of  force  on  the  broad  ligaments  as  caught  up 
by  sutures.  The  pouching  vaginal  wall  between  X  and  Y  takes  the  form  of  extreme  cys- 
tocele. 

Before  describing  the  proposed  operation  I  would  repeat  the  fact 
that  the  various  plastic  operations  on  the  vaginal  walls  (elytrorrhaphy) 
have  proved  so  unsatisfactory  that  many  surgeons  are  inclined  to 
abandon  them  and  to  adopt  the  radical  measure  of  vaginal  hysterec- 
tomy in  their  place.  This  operation,  however,  if  performed  by  the 
familiar  method  of  ligating  the  broad  ligaments,  cutting  them  from  the 
uterus,  and  then  letting  them  retract  to  the  sides  of  the  pelvis,  is  in- 
adequate, because  the  ligaments  thus  retracted  cannot  perform  their 
functions  of  holding  up  the  pelvic  floor ;  consequently,  many  hyster- 
ectomies performed  in  this  way  have  been  followed  by  a  continuance 
of  the  downward  displacement  of  the  rectum,  vagina,  and  bladder,  a 
condition  not  materially  improved  by  the  mere  absence  of  the  uterus. 
In  order  to  utilize  the  normal  supporting  power  of  the  ligaments,  I 
devised  and  in  1902  published  an  operation  by  which  the  severed  liga- 
ments were  approximated  end  to  end  between  the  peritoneal  and  vagi- 
nal sides  of  the  wound  made  by  the  removal  of  the  uterus.      In  a 

40 


654  DISPLA  CEMENTS. 

foregoing  part  of  this  chapter  I  have  introduced  this  operation  un- 
modified, because  I  desire  to  make  use  of  the  principle  of  end-to-end 
apjjroxiraation  in  the  surgical  treatment  of  complete  descent  of  the 
uterus,  a  description  of  Avhich  will  follow.  Figure  354  will  serve  to 
illustrate  the  treatment  of  the  broad  ligaments  by  end-to-end  approxi- 
mation in  vaginal  hysterectomy. 

Elytrorrliaphy,  Including  End-to-end  Approximation  of  the  Broad 
Ligaments  and  Excision  of  the  Cystocele} — The  mechanism  of  descent 
would  suggest  at  once  shortening  of  the  uterosacral  ligaments  to  draw 
the  cervix  uteri  back  to  its  normal  location  near  the  hollow  of  the 
sacrum,  and  shortening  the  round  ligaments  to  draM^  the  corpus  for- 
ward so  as  to  restore  the  normal  direction  of  the  uterine  axis.  These 
procedures  might  be  curative  in  cases  of  retroversion  or  retroflexion 
without  great  descent,  but  when  not  only  the  uterus,  but  also  the 
whole  pelvic  floor,  is  in  extreme  downward  hernial  displacement  the 
uterosacral  and  round  ligaments,  even  though  shortened,  do  not  have 
sufficient  power  to  give  permanent  support.  The  strain  on  them  is  so 
great  that  they  are  apt  to  stretch  out  and  permit  the  descent  to  recur. 
Adequate  sustaining  power  under  the  uterus  is  essential.  To  appre- 
ciate the  part  which  the  broad  ligaments  properly  may  have  in  a  cor- 
rect operation,  it  is  only  necessary  to  observe  the  fact  that  vaginal 
hysterectomy,  as  above  described,  results  in  holding  up  the  pelvic  floor 
and  with  it  the  rectum,  vagina,  and  bladder,  because  in  this  operation 
the  broad  ligaments  are  fixed  to  the  vaginal  wound.  Since  the  con- 
dition of  procidentia  is  hernia  not  alone  of  the  uterus,  but  of  the  rectum, 
vagina,  and  bladder  as  well,  let  us  try  to  hold  up  the  pelvic  floor, 
including  the  uterus,  by  similar  means,  even  though  the  uterus  be  not 
removed. 

Following  the  suggestion  of  Emmet,  Sims,  Reynolds,  and  others 
who  have  striven  to  draw  structures  in  the  neighborhood  of  the  lower 
margins  of  the  ligaments  in  front  of  the  cervix  for  the  purpose  of 
forcing  it  back,  I  found  myself  stripping  the  structures  more  and 
more  from  the  sides  of  the  uterus  and  drawing  them  in  front  of  it,  but 
not  until  I  actuallv  severed  a  considerable  portion  of  each  ligament 
from  the  sides  of  the  uterus  did  I  secure  the  best  results.  In  future 
operations  I  shall  emphasize  that  part  of  the  procedure  as  shown  in  the 
drawings  more  than  I  have  done  yet.  Figures  357  to  365,  with  their 
legends,  will  illustrate  the  proposed  method  of  holding  up  not  only 
the  uterus,  but  also  the  rectum,  vagina,  and  bladder  by  end-to-eud 
approximation  of  the  broad  ligaments  and  adequate  excision  of  the 
cystocele,  without  removal  of  the  uterus. 

In  addition  to  approximation  of  ligaments,  it  must  be  borne  in 
mind  that  other  supporting  structures  also  are  brought  together  in 
front  of  the  cervix  uteri,  notably  the  adjacent  parametric  structures, 
and  if  the  operation  is  sufficiently  extensive,  the  round  ligaments.  In 
extreme  cases  it  would  be  well  to  separate  the  bladder  entirely  from 
the  cervix  uteri,  as  would  be  done  in  vaginal  section,  so  as  to  expose 
the  round  ligaments.     These  ligaments  then  could  be  brought  down 

1  Read  in  the  Section  on  Obstetrics  and  Diseases  of  Women  of  the  American  Medical  Asso- 
ciation, at  Boston,  June,  1906. 


MAL-LOCATIONS  OF  THE   UTERUS.  655 

in  front  of  the  cervix  and  included  in  the  sutures  which  are  used  to 
approximate  the  cut  ends  of  the  broad-  ligaments.  Such  adjustment 
of  the  broad  and  round  ligaments,  together  with- adjacent  parametria 
in  front  of  the  cervix,  necessarily  would  give  great  strength  to  the 
pelvic  floor. 

The  question  frequently  has  been  asked  whether  in  cutting  away 
the  lower  halves  of  the  broad  ligaments  troublesome  hemorrhage  is  not 
encountered.  I  should  fear  such  hemorrhage  if  the  ligaments  were 
severed  with  the  uterus  in  its  normal  location,  but  would  not  fear  it 
with  the  uterus  outside  the  body.  Besides,  since  a  shaving  is  removed 
from  each  side  of  the  uterus,  the  incision  usually  would  be  safely 
inside  the  utero-ovarian  anastomosis.  At  any  rate,  the  uterus  being 
outside  the  body,  hemorrhage  can  be  controlled  easily  if  it  does  occur. 
Even  at  the  risk  of  prolixity,  I  repeat  that  it  is  essential  to  remove 
the  entire  thickness  of  the  vaginal  layer  of  the  vesicovaginal  septum, 
as  shown  in  Figure  357.  The  illustrations  of  this  operation  here 
show  the  cervix  uteri  drawn  well  down  to  the  vulva,  but  this  appear- 
ance is  introduced  only  to  facilitate  the  illustration ;  the  suturing  part 
of  the  operation  should  be  performed  so  far  as  possible  with  the  cervix 
in  the  hollow  of  the  sacrum  where  the  operation  is  designed  to  fix  it. 
The  incisions  may  be  made  with  the  uterus  drawn  down,  but  it  is 
well  to  introduce  the  sutures  with  the  cervix  uteri  in  place,  and  to 
this  end  the  left  lateroprone  position  and  Sims'  speculum  may  be 
used  advantageously.  The  author  uses  a  speculum  with  the  blade 
perforated  at  its  extreme  end,  and  before  the  speculum  is  intro- 
duced the  cervix  is  attached  to  the  end  of  the  blade  by  means  of  a 
temporary  suture  which  is  passed  through  the  posterior  lip  of  the 
cervix  and  then  through  the  perforation  in  the  speculum,  and  tied. 
This  temporary  stitch,  while  the  sutures  are  being  applied,  holds  the 
cervix  far  back  in  the  hollow  of  the  sacrum  ;  it  should  be  removed  at 
the  end  of  the  operation.  When  the  cervix  thus  is  held  back,  the 
space  anterior  to  the  uterus  is  so  increased  that  the  uterus  readily  falls 
forward  into  a  position  of  decided  anteversion  and  shows  the  advan- 
tage of  doing  the  operation  with  the  organ  in  normal  position. 

Contraindication  to  Elytrorrhaphy. — Elytrorrhaphy  is  usually  unnec- 
essary and  therefore  contraindicated  in  descent  of  the  first  degree. 
The  special  province  of  the  operation  is  in  complete  prolapse  or  pro- 
cidentia iKhen  associated  with  cystocele.  The  operation  further  is  con- 
traindicated by  tumors  and  adhesions  which  render  replacement  and 
retention  impossible,  and  in  diseases  of  the  uterus  or  its  appendages 
which  demand  their  removal.  When  such  contraindications  do  not 
exist,  unless  the  descent  is  extreme,  elytrorrhaphy  and  perineorrhaphy 
are,  usually  at  least,  quite  as  effective,  and  are  therefore  to  be  pre- 
ferred to  the  more  dangerous  and  mutilating  hysterectomy. 

Perineorrhaphy. — As  already  stated,  it  is  most  important  to 
appreciate  the  fact  that  in  nearly  every  case  of  procidentia  the  lower 
extremity  of  the  vagina  is  displaced  backward.  This  is  consequent 
upon  subinvolution  of  the  vaginal  walls,  and  especially  upon  subin- 
volution or  rupture  of  the  perineum  or  of  some  other  portion  of  the 
vaginal  outlet.     Unless,  therefore,  the  posterior  wall  of  the  vagina 


656 


JDISPLA  CEMENTS. 


FlGTJEE   357. 


Broad  ligament  operation  for  complete  descent  of  the  uterus.  Cervix  held  steady  by  flat 
vulsellum  forceps.  The  bladder  lies  in  front  of  the  prolapsed  uterus.  The  dotted  hue  extend- 
ing in  the  median  direction  on  the  anterior  wall  of  the  cervix  from  a  point  at  the  uterovaginal 
attachment  to  the  urethrovaginal  wall,  marks  the  direction  of  an  incision  to  be  made  by  means 
of  sharp-pointed  scissors  through  the  vaginal  laver  of  the  vesicovaginal  septum.  The  incision 
extending  around  the  anterior  half  of  the  cervix  at  the  uterovaginal  attachment  is  made 
through  the  vaginal  wall  to,  but  not  into,  uterine  tissue. 


Figure  358 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  Bladder  being  stripped 
from  uterus  by  blunt  dissection,  which  is  accomplished  readily  and  quickly  by  sponge 
pressure,  and  is  continued  to  the  peritoneal  reflexion  of  the  vesico-uterine  pouch  precisely 
as  it  would  be  if  the  operator  were  going  to  open  into  the  peritoneal  cavity  between  the 
uterus  and  bladder.  Observe  here,  just  beneath  the  sponge,  the  translucent  peritoneum, 
which  for  the  present  purpose  is  not  usually  to  be  incised. 


657 


Figure  359 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  bladder  has  been 
stripped  from  the  uterus,  and  the  peritoneum  exposed  (Figure  358),  the  vesicovaginal  septum 
is  drawn  down  over  the  anterior  uterine  wall  by  a  forceps,  and  the  vaginal  layer  of  the 
septum  is  being  split  on  the  median  line  with  scissors. 


Go8 


Figure  360 


Broad  Ligament  Operation  for  Complete  Descent  of  the  L'terus.  The  vaginal  layer 
of  the  vesicovaginal  septum  is  being  stripped  away  from  the  bladder  wall  by  the  same  Kind 
of  blunt  dissection  used  in  Figure  358.  The  bladder  as  it  is  separated  is  pushed  up  out  of 
sight. 


659 


Figure  361 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  lower  two-thirds  of 
each  broad  ligament,  and.  to  avoid  wounding  the  utero-ovarian  anastomosis,  a  thin  shaving 
also  of  the  cervix  are  being  cut  away  with  sharp-pointed  scissors.  The  right  ligament  has 
been  severed  and  the  left  is  being  severed.  The  redundant  vaginal  layer  (cystocele)  which 
has  been  stripped  off  from  the  bladder  is  held  by  forceps  out  of  the  way  to  either  side. 


660 


Figure  362 


Broad  Ligament  Operation  for  Complete  Descent  of  the  ITterus.  The  severed  lower 
two-thirds  of  the  broad  ligaments  are  being  approximated  end  to  end  by  catgut  sutures. 
First  suture  in  place  and  being  drawn  tight.  These  ends  as  they  are  drawn  together  already 
are  forcing  the  cervix  back.  As  already  explained,  the  cut  ends  of  these  ligaments  when 
united  pull  down  together  with  them  the  adjacent  parametric  structures  and  in  extensive 
operations  also  the  round  ligaments.  Too  tight  tying  is  apt  to  strangulate  the  tissues, 
cause  the  sutures  to  cut  out,  and  prevent  union.  No.  1  or  No.  2  chromic  catgut 
ordinarily  is  used.     Silkworm  gut  is  better,  but  difficult  to  remove. 


661 


Figure  363 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  lower  two-thirds 
of  the  severed  broad  ligaments  have  been  united  end  to  end  by  catgut  sutures,  thus  forcing 
the  cer\-ix  still  farther  back.  The  redundant  vaginal  wall  (cystocele)  has  been  cut  away 
on  the  right  and  is  being  cut  away  on  the  left.  The  entire  thickness  of  the  vaginal  wall  is 
being  cut  away;  this  is  in  contrast  to  the  older  method  of  superficial  denudation. 


662 


Figure  364 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  severed  ends  of  the 
broad  ligamenthaving  been  united  in  front  of  the  cervix  and  the  cystocele  excised,  the  cut 
edges  of  the  vaginal  wall  are  being  approximated  from  side  to  side.  The  first  suture, 
which  is  being  drawn  tight,  shows  how  the  margins  are  approximated  near  the  cervix.  The 
other  sutures  show  the  method  of  union  between  this  first  suture  and  the  others,  which 
are  introduced  but  not  tied.  Observe  that  these  sutures  all  catch  up  the  uterine  wall, 
thus  forcing  the  bladder  up  so  that  it  cannot  come  down  again  between  the  uterus  and  the 
vagina.     This  forcing  up  the  bladder  is  a  very  essential  factor  in  the  success  of  the  operation. 


663 


Figure  365 


#_% 


/^ 


Broad  Ligament  Operation  for  Complete  Descent  of  the  Uterus.  The  redundant  vaginal 
wall  having  been  removed  (Figure  363)  the  lateral  margins  of  the  vaginal  wound  are  being 
united  by  interrupted  sutures.  As  the  result  of  this  union  the  cervix  and  upper  end  of 
the  vagina  have  been  forced  back  to  their  normal  location  in  the  hollow  of  the  sacrum. 
B  and  C  show  the  lines  of  union  complete.  At  the  urethral  end  of  the  wound  the  redundant 
vaginal  wall  cannot  be  disposed  of  always  by  a  median  line  of  union.  It  may  be  necessary, 
as  shown  here,  to  unite  that  part  in  a  direction  at  the  right  angles  to  the  main  line  of  union.' 
Traction  is  being  made  by  tenacula  at  each  end  of  this  transverse  line  of  union.  The  cervical 
lines  of  union  also  have  the  T-shape. 


664 


MAL-LOCATIONS  OF  THE   UTERUS.  665 

and  the  perineum  can  be  brought  forward  to  their  normal  location 
under  the  pubes,  so  as  to  give  support  to  the  anterior  vaginal  wall, 
the  latter  will  fall  again,  will  drag  the  uterus  after  it,  and  the  hernial 
protrusion  will  be  reproduced.  The  treatment,  therefore,  of  complete 
procidentia  must  always  include  an  adequate  operation  upon  the  peri- 
neum, or,  more  comprehensively  speaking,  upon  the  posterior  wall  of  the 
vaginal  outlet.  The  operation  must  be  performed  so  that  it  will  carry 
the  lower  extremity  of  the  vagina  forward  to  the  normal  location  close 
up  under  the  pubes  ;  then,  if  the  anterior  elytrorrhaphy  is  adequate, 
the  whole  vagina  will  have  its  normal  oblique  direction,  and  its  long 
axis  will  make  an  acute  angle  to  the  long  axis  of  the  uterus.  When 
this  angle  is  maintained,  the  uterus  cannot  easily  turn  the  sharp 
corner  which  will  bring  its  long  axis  into  coincidence  with  that  of 
the  vagina,  and  cannot,  therefore,  readily  prolapse.  See  Chapter  on 
Perineorrhaphy. 

Comparison  of  Elytrorrhaphy  and  Hysterectomy. — As  laid  down  in 
the  foregoing  paragraphs,  the  utilization  of  the  broad  ligaments  is  an 
essential  factor  in  the  treatment  of  complete  procidentia.  The  opera- 
tion of  elytrorrhaphy  above  described  unfortunately  either  may  fail 
to  bring  the  lower  edges  of  the  broad  ligaments  sufficiently  to  the 
front  of  the  uterus  to  enable  them  to  hold  up  the  uterus  and  vagina,  or 
the  ligaments  having  been  stitched  in  front  of  the  uterus  the  stitches 
may  not  hold.  Consequently  in  complete  procidentia  elytrorrhaphy 
even  though  well  performed  may  fail.  At  least  this  has  been  the 
author's  experience  in  a  number  of  cases.  Therefore  the  completely 
prolapsed  uterus  may  have  to  be  removed  in  order  to  anchor  abso- 
lutely the  cut  ends  of  the  broad  ligaments  to  the  upper  part  of  the 
vagina.  As  before  stated,  the  operation  should  include  the  treatment 
of  the  hernial  factor  in  the  lesion — that  is,  removal  of  the  redun- 
dant portion  of  the  anterior  vaginal  wall.  Generally  speaking,  the 
indications  are  somewhat  as  follows  : 

1.  Extreme  cystocele  not  associated  with  complete  procidentia 
should  be  treated  by  elytrorrhaphy  and  perineorrhaphy. 

2.  Extreme  cystocele  associated  with  complete  procidentia  properly 
may  be  treated  by  hysterectomy,  elytrorrhaphy,  and  perineorrhaphy. 

3.  Conditions  intermediate  between  the  two  conditions  indicated 
above,  and  cases  of  very  feeble  or  very  aged  women,  will  call  for  spe- 
cial judgment  whether  hysterectomy  should  be  omitted  or  performed. 
It  is,  however,  a  fortunate  fact  that  the  completely  prolapsed  uterus 
even  in  aged  women  is  removed  usually  with  ease  and  with  safety. 

The  indication  for  perineorrhaphy  as  a  supplement  to  hysterectomy 
is  the  same  as  it  is  after  elytrorrhaphy.  After  the  senile  changes  of 
the  menopause  vaginal  hysterectomy  for  obvious  reasons  is  relatively 
unobjectionable,  and  in  many  cases  may  be  preferred  to  elytrorrhaphy. 
In  connection  with  hysterectomy,  however,  the  removal  of  a  portion 
of  the  anterior  vaginal  wall  usually  will  be  required. 

Other  Operations  designed  to  decrease  the  weight  of  the  uterus 
by  removal  of  a  part  of  it  are  of  questionable  value.  The  treatment 
of  increased  weight,  due  to  subinvolution,  hypertrophy,  congestion, 
hyperplasia,  and  tumors,  is  described  elsewhere  under  those  subjects. 


666  DISPLACEMENTS. 

Amputation  of  the  cervix  to  lighten  the  weight  of  the  uterus  has 
been  practised  much  for  the  spurious  circular  hypertrophy  and  hyper- 
trophic elongation  shown  in  Figure  353.  Since  these  two  conditions 
are  rare,  if  not  indeed  unknown,  it  follows  that  they  could  seldom  fur- 
nish an  indication  for  amputation  of  the  ceryix  uteri.  It  is,  in  fact, 
difficult  to  imagine  a  class  of  cases  in  which  this  operation  would 
be  indicated.  Emmet's  explanation  of  the  pathology  of  this  class  of 
cases  has  led  to  the  substitution  of  trachelorrhaphy  or  of  Schroeder's 
operation  for  amputation  of  the  ceryix. 

Tumors  increasing  the  weight  of  the  uterus  and  tumors  exerting 
pressure  from  above  or  traction  from  below  should,  if  practicable,  be 
removed. 

Alexander's  operation  and  abdominal  hysterorrhaphy  are  described 
under  the  surgical  treatment  of  retroversion  and  retroflexion.  The 
object  of  these  operations  is  to  suspend  the  uterus  from  above.  Hys- 
terorrhaphy, which  fulfils  this  indication  better  than  shortening  the 
round  ligaments,  may  be  indicated  in  cases  of  extreme  relaxation  of 
the  uterine  supports  and  greatly  increased  weight  of  the  uterus.  The 
results  of  it  in  procidentia,  however,  will  usually  not  be  permanent 
unless  it  is  supplemented  by  elytrorrhaphy  and  perineorrhaphy. 

Enteroptosis  as  a  Complication  of  Descent  of  the  Uterus. 

In  many  cases  of  descent  of  the  uterus  the  displacement  is  aggra- 
vated by  alterations  in  abdominal  pressure  associated  with  descent  of 
the  abdominal  viscera,  especially  the  stomach  and  intestine.  These 
conditions  are  gastroptosis  and  enteroptosis.  "Webster  has  laid  stress 
upon  the  fact  that  general  %yeakness  and  laxity  of  the  abdominal  wall 
are  not,  as  usually  supposed,  the  cause  of  the  enteroptosis,  but  that 
descent  of  the  viscera  is  caused  by  excessive  separation  of  the  recti 
muscle,  due  to  stretching  of  the  linea  alba.  All  conditions  that  in- 
crease abdominal  pressure,  especially  during  pregnancy,  such  as  the 
wearing  of  corsets  and  overwork,  predispose  to  enteroptosis.  Loss  of 
fat  is  also  a  cause  of  enteroptosis. 

Success  in  the  treatment  of  uterine  displacement  will  depend  fre- 
quently upon  associating  with  it  some  eiFective  measure  for  the  cor- 
rection of  the  pendulous  abdomen — that  is,  of  the  enteroptosis. 
Temporary  correction  may  be  secured  by  a  properly  fitting  abdominal 
bandage.  Permanent  correction  in  most  cases  will  require  abdom- 
inal section  and  such  closure  of  the  wound  as  will  correct  the  diastasis 
of  the  recti  muscles.  The  operation  is  the  same  in  ])rinciple  as  that 
described  by  Edebohls  for  closure  of  the  abdominal  wound,  an  opera- 
tion set  forth  in  Chapter  VI.  In  this  operation  it  was  not  proposed 
to  open  the  abdomen  for  the  purpose  of  treating  enteroptosis,  but,  the 
abdomen  having  been  opened  for  other  purposes,  to  close  it  in  such  a 
manner  as  to  overcome  any  pendulous  condition  that  might  exist. 
The  operation  proposed  by  AVebster  is  the  deliberate  opening  of  the 
abdomen  for  the  cure  of  enteroptosis.  It  is  much  the  same  as  that 
which  for  a  long  time  has  been  performed  for  the  relief  of  ventral 
hernia,  and  is  substantially  as  follows  : 


MAL-LOCATIONS  OF  THE   UTERUS.  667 

An  incision  is  made  in  the  median  line  dividing  the  skin  and  sub- 
cutaneous fat  until  the  linea  alba  is  exposed.  The  length  of  the 
incision  should  vary  with  the  extent  of  the  separation  of  the  recti 
muscles.  In  aggravated  cases  it  should  extend  from  the  symphysis 
pubis  nearly  to  the  ensiform  cartilage.  The  umbilicus,  if  deep  and 
difficult  to  clean  thoroughly,  should  be  removed ;  otherwise  the  mesial 
incision  may  be  carried  around  to  the  left  of  it.  The  skin  and  fat 
should  be  dissected  from  the  fascia  on  both  sides,  so  as  to  expose  the 
edge  of  each  rectus  muscle.  The  sheath  of  each  muscle  is  then  split 
lono'itudinallv  along  the  inner  border  and  the  incision  continued  to  the 
extent  of  the  diastasis.  The  inner  borders  of  the  muscles  are  then 
loosened  from  the  sheaths  and  united  by  a  series  of  sutures  passed 
from  side  to  side  through  each  muscle  and  the  corresponding  anterior 
fascia  or  sheath  layer.  These  sutures  when  tied  will  obliterate  the 
stretched-out  linea  alba,  approximate  tiie  muscles  and  cover  them  with 
fascia.  Webster  recommends  strong  linen  sutures,  which  are  left  per- 
manently buried.  The  author  uses  chromic  catgut  as  a  continuous 
suture  throughout.  See  Chapter  VI.  Some  bulging  of  the  skin  may 
follow  the  reduction  in  the  size  of  the  inner  abdominal  wall,  but  after 
a  little  time  this  usually  disappears.  In  cases  of  excessive  relaxation 
a  strip  of  fat  and  skin  may  be  removed  before  passing;  the  superficial 
sutures.  The  use  of  a  broad  silk  elastic  binder,  daily  massage  of  the 
abdominal  parietes,  followed  later  by  light  gymnastic  exercise  and 
abstinence  from  severe  exertion  during  a  period  of  six  months,  are 
recommended  as  part  of  the  after-treatment. 

On  the  suggestion  of  Edebohls,  tlie  author  has  for  several  years, 
when  closing  the  abdominal  incision,  felt  himself  justified  in  splitting 
the  sheaths  of  the  recti  muscles  and  bringing  the  fascia  together  with 
continuous  chromic  catgut  sutures  as  a  means  of  protection  against 
possible  diastasis  of  those  muscles  and  consequent  enteroptosis. 


CHAPTEE    XLVI. 

ETIOLOGY,   SYMPTOMS,   COURSE,   DIAGNOSIS  AND  PROG- 
NOSIS OF  RETROVERSION  AND  RETROFLEXION. 

RETROVERSION. 

Reteoversion  is  that  abnormal  position  of  the  uterus  in  which 
the  fundus  is  posterior  to  the  axis  of  tlie  pelvic  inlet.  If  the  cervix 
be  in  its  normal  place,  near  the  sacrum,  retroversion  is  scarcely- 
possible,  because  prevented  by  the  proximity  of  the  over-arching 
sacrum.  See  Figure  341.  The  first  degree  of  prolapse  must,  usually, 
precede  any  considerable  backward  turning  of  the  uterus.  When  the 
cervix  has  been  displaced  downward  and  forward  so  far  that  its  dis- 
tance from  the  sacrum  is  equal  to  or  greater  than  the  length  of  the 
uterus,  retroversion  to  any  extent  becomes  possible.     See  Figure  366. 

Etiology  and  Description  of  Retroversion. 

From  the  above  it  follows  that  the  causes  of  beginning  retrover- 
sion must  be  identical  with  the  causes  of  the  first  degree  of  prolapse. 
After  the  puerperium  the  relaxation  of  the  supports  and  the  weight  of 
the  displaced  organ  may  persist,  and  this,  together  with  the  pressure 
and  weight  of  the  intestine  upon  the  anterior  surfaces  of  the  uterus, 
may  prevent  spontaneous  replacement.  Every  act  of  defecation  forces 
the  cervix  forward  and  downward,  and  the  uterus,  being  in  the  axis 
of  the  vagina,  and  having,  therefore,  little  support  below,  must  depend 
for  support  upon  the  now  inadequate  subinvoluted  peritoneal  suspen- 
sory ligaments  and  pelvic  fiiscia.  Abortion,  with  resulting  increased 
weight  and  relaxation  of  the  vaginal  walls,  is  a  common  cause  of 
descent.  Metritis,  parametritis,  perimetritis,  peritonitis,  salpingitis, 
and  ovaritis  are  frequent  complications,  and  may  stand  in  the  relation 
of  cause  or  effect. 

Congenital  retroversion  is  rare.  Retroposition  of  the  small  senile 
uterus  after  the  menopause  is  not  abnormal.  Peritoneal  adhesions 
and  cicatricial  bands  may  fix  permanently  the  corpus  in  a  retro  verted 
position.  In  extreme  retroversion  the  corpus  often  is  incarcerated 
between  the  iiterosacral  ligaments  under  the  promontory  of  the  sacrum. 
Chronic  cystitis  and  consequent  contraction  of  the  bladder  shorten 
the  vesicovaginal  wall,  and  thereby  draw  the  cervix  forward.  This 
makes  a  permanent  incurable  displacement. 

The  causes  of  retroversion  may  be  summarized  as  follows : 

1.  Distention  of  the  bladder. 

2.  Increased  weight  of  the  uterus  and  relaxation  of  the  supports 

— common  cause  in  early  puerperium. 

3.  Retro-uterine  peritonitis — contractingadhesions. 

668  '  ' 


RETROVERSION  AND  RETROFLEXION. 


669 


4.  Sudden  straining,  violent  fall,  or  blow — rare. 

5.  Chronic  cystitis,  which  shortens  the  vesicovaginal  septum  by 

contraction — an  intractable  cause. 

6.  Small  myoma  in  posterior  wall  of  the  corpus  uteri. 

7.  The  dorsal  position  and  tight  bandaging  in  the  puerperium. 

8.  Congenital— rare. 

Symptoms  and  Course  of  Retroversion. 

The  displacement  of  retroversion  and  its  numerous  complications 
usually  cause  bearing-down  sensations,  a  feeling  of  heaviness  in  the 
peliig,  exhaustion  upon  walking^  and  standing,  especially  the  latter. 
Constipation  may  be  a  cause  or  an  effect.  After  the  puerperium  the 
extreme  engorgement  of  the  pelvic  organs  often  contributes  to  hemor- 
rhagic endometritis.     The  hemorrhage  then  should  not  be  confounded 

Figure  366. 


Retroversion. 


with  returning  menstruation.  The  bleeding,  especially  after  abortion, 
unless  relieved  by  treatment,  often  persists  for  a  long  time.  Gradual 
or_5iidden  replacement  may  occur  spontaneously  ;  or,  the  causes  con- 
tinuing active,  the  displacement  may  persist  and  even  be  reinforced 
by  cystocele  and  rectocele.  There  is  usually  concurrent  displacement 
of  the  ovaries  and  Fallopian  tubes.  Nutritive  changes  in  the  uterine 
walls  may  induce  a  superadded  retroflexion.  The  heavy  organ  may 
descend  along  the  relaxed,  subinvoluted  vaginal  walls  even  to  com- 
plete procidentia. 


670 


DISPLA  CEMENTS. 


Diagnosis  and  Prognosis  of  Retroversion. 

The  symptoms  indicate  the  probability  of  displacement,  but  definite 
diagnosis  depends  upon  direct  examination.  Conjoined  manipulation 
will  usually  establish  the  diagnosis  and  show  the  organ  retroverted, 
with  the  ceryix  displaced  toward  the  pubes  and  with  the  corpus  in 
the  hollow  of  the  sacrum.  In  certain  cases  of  anteflexion,  as  repre- 
sented in  Chapter  XLVIII.,  the  ceryix  is  bent  forward  in  the  vaginal 


/.."T: 


FiGUKE  367. 


Degrees  of  retroversion  » 


axis  as  in  retroversion.  The  condition  is  in  reality  one  of  retroversion 
of  the  cervix,  with  high  anteflexion  of  the  corpus.  Under  treatment, 
the  prognosis,  both  for  speedy  relief  and  ultimate  recovery,  is  gene- 
rally favorable. 

Degrees  of  Retroversion. 

Retroversion  will  be  slight  or  extreme  according  to  the  extent  to 
which  the  axis  of  the  uterus  is  turned  back.  Three  degrees  of  dis- 
placement usually  are  recognized ;  but  the  division  is  arbitrary,  and, 
except  for  purposes  of  description,  has  no  practical  significance.     See 

»  Suggested  by  Penrose.    Diseases  of  Women. 


RETROVERSION  AND  RETROFLEXION. 


671 


Treatment  of  Retroversion. 

The  treatment,  as  in  descent,  consists  of  the  removal  of  the  inflam- 
matory and  other  complications,  in  the  use  of  pessaries,  and  in  surgi- 
cal operations.  Inasmuch  as  the  treatment  is  similar  to  that  of 
retroflexion,  the  treatment  of  retroversion  and  retroflexion  will  be 
presented  together.     See  Chapter  XLVII. 


RETROFLEXION. 

Retroflexion  is  that  displacement  in  which  the  organ  is  bent  back 
upon  itself.     It  usually,  though  not  always,  results  from,  and  is  asso- 

FiGtJEE  368. 


Extreme  retroflexion  with  hypertrophy  of  the  corpus  uteri.    The  uterus  impinges  on  and 
compresses  the  rectum. 

ciated  with,  retroversion ;  in  accordance  with  custom,  the  double  dis- 
placement will  be  termed  retroflexion. 

Etiology  and  Pathology  of  Retroflexion. 

The  causes  of  retroflexion  are  identical  with  those  of  retroversion, 
which  to  a  very  great  extent  may  be  summarized  as  follows  : 

1.  All  causes  of  retroversion,  see  Descent  and  Retroversion. 

2.  The  dorsal  position  and  tight  bandaging  in  the  puerperium. 

3.  Tight  lacing  and  tight  clothing. 


672  DISPLACEMENTS. 

4.  An   infectious   puerperium   impairing   the   nutrition    of  the 

uterine  walls  and  uterine  supports. 

5.  Pressure  by  tumors. 

6.  Congenital  conditions — rare  and  usually  associated  with  under- 

development of  the  other  reproductive  organs; 

7.  Great  weight  of  the  corpus  uteri. 

8.  Soft  mobile  condition  of  the  uterine  walls — common  during 

the  puerperium. 

9.  Intra-abdominal  forces,   such  as  downward  pressure  during 

defecation. 

10.  Metritis  and  perimetritis,  especially  when  associated  with 
post-uterine  adhesions. 

The  ovaries  and  Fallopian  tubes,  unless  fixed  elsewhere  by  adhe- 
sions, are  held  down  usually  on  either  side  of  the  corpus  uteri.  They 
are  sometimes  much  enlarged  by  inflammation,  often  adherent,  and 
always  extremely  sensitive.  Infection  of  the  uterus  and  its  append- 
ages from  bacterial  invasion  is  almost  invariably  the  essential  cause. 
The  displacement  often  follows  parturition,  abortion,  and  injudicious 
treatment.  Gonorrhoea  and  the  puerperal  infections  are  frequent 
causes.  Peritoneal  adhesions  between  the  corpus  uteri  and  the  pouch 
of  Douglas  may  render  replacement  impossible,  except  by  abdominal 
or  vaginal  section. 

Symptoms  and  Course  of  Retroflexion. 

In  some  cases  there  are  no  subjective  symptoms.  The  conditions 
frequently  associated  with  retroflexion  are  these : 

1.  Sterility  and  frequent  abortion. 

2.  Uterine  discharges — leucorrhcea. 

3.  Menstrual  disorders — dysmenorrhoea,   amenorrhoea,    uterine 

hemorrhages. 

4.  Constipation  and  painful  defecation. 

5.  Bladder  disturbances. 

6.  Weakness  in  the  back  and  dragging  sensation   in  the  pelvis. 
Uterine   discharges,   menorrhagia,   and   abortion   usually  are  the 

result  of  associated  endometritis,  and  are  due  to  the  effort  of  an 
engorged  uterus  to  relieve  itself  of  congestion  by  increased  secretions 
or  increased  menstruation. 

Abortion,  dysmenorrhoea,  and  sterility  may  result  from  a  wide 
range  of  associated  conditions,  chief  among  them  faulty  nutrition, 
inflammatory  complications,  and  mechanical  obstruction  in  the  uterine 
canal  at  the  angle  of  flexure.  The  rectal  symptoms  are  caused  by  the 
proximity  of  the  inflamed  uterus,  and  its  appendages,  to  the  bowel. 
This  gives  to  the  patient  the  sensation  of  a  full  bowel,  and  is  there- 
fore a  cause  of  tenesmus.  Passage  of  the  bowel-contents  through 
this  sensitive  zone  is  necessarily  painful.  Abdominal  pains,  nervous 
dyspepsia,  neuralgia  in  distant  parts  of  the  body,  and  neurasthenia 
are  often  present ;  indeed,  the  nervous  symptoms  may  be  of  the  most 
exaggerated^  character,  and  may  comprise  all  that  is  implied  by  the 
word  hysteria  in  its  most  comprehensive  signification. 


RETROVERSION  AND  RETROFLEXION.  673 

Should  pregnancy  occur,  the  rapid  growth  of  the  uterus  may  induce 
spontaneous  reposition ;  this  is  likely  to  take  place  when  the  fundus 
rises  out  of  the  pelvis  at  about  the  fourth  month ;  but  if  the  corpus 
be  incarcerated  under  the  sacral  promontory  from  adhesions  or  from 
any  other  cause,  the  uterus,  unless  manually  replaced,  will  relieve 
itself  by  a  dangerous  abortion. 

Diagnosis  of  Retroflexion. 

The  diagnosis  should  include  especially  an  inquiry  into : 

1.  The  location  and  position  of  the  uterus  relative  to  neighbor- 

ing organs. 

2.  The  mobility  of  the  uterus. 

3.  The  complications. 

Digital  touch  discloses  the  cervix  uteri  low  in  the  pelvis.  The 
fundus  uteri  is  felt  through  the  posterior  vaginal  wall  in  the  cul-de-sac 
of  Douglas.  Conjoined  manipulation  with  the  index-finger  of  the  left 
hand,  first  in  the  vagina,  then  in  the  rectum,  and  the  right  hand  over 
the  hypogastric  region,  will  show  the  size,  form,  consistence,  and  loca- 
tion of  the  uterus,  the  degree  of  flexion,  and  the  difficulty  of  replace- 
ment. An  inflammatory  deposit  or  abscess  posterior  to  the  uterus, 
or  a  fibroid  in  the  posterior  uterine  wall,  may  be  mistaken  for  the 
retroflexed  corpus.  The  probe  is  seldom  necessary  to  verify  the  diag- 
nosis. It  should  be  used  under  strict  antiseptic  conditions,  for  other- 
wise additional  infection  may  be  introduced.  In  some  cases  of  difficult 
diagnosis  it  is  better  at  first  to  direct  the  treatment  to  the  inflamma- 
tion and  defer  the  precise  diagnosis  of  the  displacement  to  a  later  date. 
Great  and  lasting  injury  may  be  wrought  in  the  attempt  to  complete 
the  diagnosis  at  the  first  examination.  The  presence  of  a  small 
myoma  in  the  posterior  uterine  wall,  wnth  post-uterine  inflammation, 
is  a  serious  complication  both  in  diagnosis  and  treatment.  If  the 
rectum  be  loaded  with  fecal  matter,  a  cathartic  should  be  given  and 
the  complete  digital  examination  deferred.  The  displacement  is  dis- 
tinguished from  the  presence  of  an  ovary  or  small  ovarian  tumor  in 
the  pouch  of  Douglas,  by  careful  bimanual  examination  and  by  the 
probe. 

Diagnosis  in  the  Puerperium. — Uterine  hemorrhage  which 
begins  two  or  three  weeks  after  labor,  and  small  daily  losses  of  blood 
during  the  puerperium,- are  evidences  though  not  proof  of  retro- 
displacement. 

Diagnosis  of  Complications. — The  following  complications  may 
have  the  relation  either  of  cause  or  effect  to  the  displacement : 

1.  Perimetritic  fixation — result  of  perimetritis — is  recognized  by 
bands  of  adhesions  palpated  behind  and  to  the  sides  of  the  uterus 
and  felt  about  the  corpus  above  the  plane  of  the  internal  os,  near  the 
fundus.  Perimetritic  adhesions  commonly  fix  the  uterus  to  the  tubes, 
ovaries,  or  broad  ligaments,  and  such  adhesions  form  a  mass  rec- 
ognized by  conjoined  palpation. 

2.  Parametritic  fixation — result  of  parametritic  cellulitis — extends 
more  usually  below  the  plane  of  the    os  internum ;    it    draws  the 


674  DISPLACEMENTS. 

cervix  laterally,  anteriorly,  or  posteriorly  toward  the  pelvic  wall  by 
contraction  of  inflamed  celkdar  tissue,  which  is  thicker  and  more  dense 
than  in  perimetritic  adhesions,  and  lower  in  the  pelvis. 

Differential  Diagnosis  of  Retroflexion. 

The  differential  diagnosis  shoidd  include  a  consideration  of  inflam- 
matory retro-uterine  masses,  retro-uterine  myomata,  hsematocele,  and 
fecal  accumulations. 

Retro-uterine  inflammatory  products  and  myomata  in  the  poste- 
rior wall  of  the  uterus  may  be  recognized  by  the  location  of  the 
fundus  uteri  lying  in  front  of  the  mass.  Examination  should  be 
made  by : 

a.  Conjoined  palpation  with  or  without  narcosis. 
6.  The  uterine  sound — used  with  caution, 
c.  Conjoined  rectal  touch — most  important. 
The  tumor,  whether  inflammatory,  myomatous,  orhsemic,  is  usually 
wider  than  the  uterus,  often  not  situated  directly  behind  the  cervix, 
but  to  one  side,  and  may  be  irregular  in  outline.    The  contrary  is  true 
of  the  retroflexed  corpus  uteri. 

Fecal  accumulations  may  be  excluded  by  cathartics. 


CHAPTER    XLVII. 

TREATMENT  OF  RETROVEHSION  AND  RETROFLEXION. 

The  objects  of  treatment  are  replacement  and  retention  of  the 
uterus. 

Obstacles  to  Replacement. 

The  obstacles  to  replacement  are  tumors,  inflammation,  and  fixa- 
tion of  the  uterus.  The  inflammatory  complications  often  require 
weeks,  and  in  severe  cases  months,  of  treatment  preparatory  to 
replacement ;  not  uncommonly  a  tumor  must  be  removed  by  a  surgi- 
cal operation.  Some  of  the  general  therapeutic  suggestions  under  the 
subject  of  descent  are  also  applicable  to  retropositions.  Thus  rest, 
massage,  careful  regulation  of  the  bowels,  forced  feeding,  and  general 
tonics  may  be  essential. 

For  pelvic  inflammation,  small  blisters  over  the  inguinal  regions, 
frequently  repeated,  and  the  daily  application  of  a  cotton  and  glyc- 
erin tampon  to  the  cervix,  are  common  routine  measures  of  some 
value.  The  most  useful  and  essential  topical  application  is  the  hot- 
water  vaginal  douche.  The  proper  manner  of  giving  the  douche  is 
described  in  Chapter  IV.     See  also  Chapter  XXII. 

As  the  tenderness  disappears  the  cotton  tampons  may  be  increased 
in  quantity,  and  thereby  made  to  serve  as  temporary  support  for  the 
uterus  until  the  more  permanent  pessary  can  possibly  be  substituted. 
The  sluggish  circulation  in  the  pelvis  and  torpid  condition  of  the 
bowels  may  be  much  relieved  by  the  daily  application  of  the  hot  hip- 
pack  ;  it  is  applied  as  follows  : 

A  small  flannel  sheet,  folded  lengthwise  to  the  width  of  two 
feet,  dipped  in  very  hot  water  and  dried  by  passing  it  through  a 
wringer,  is  wound  about  the  hips  and  covered  by  another  dry  one. 
At  the  end  of  half  an  hour,  during  which  time  the  patient  main- 
tains the  recumbent  position,  the  sheets  are  removed.  Hot- water 
bags  between  the  wet  and  the  dry  sheet  will  serve  to  prolong  the 
heat. 

When  the  tenderness  has  been  sufficiently  reduced,  gentle  attempts 
at  replacement  may  be  made  every  day  or  two  by  conjoined  manipula- 
tion. The  patient's  tolerance  of  manipulation  may  thus  be  observed 
and  the  way  prepared  for  complete  replacement  and  permanent  reten- 
tion after  subsidence  of  the  inflammation. 

Fixation  and  tenderness,  until  overcome  by  appropriate  treatment, 
are  contraindications  to  replacement. 

675 


676  DISPLACEMENTS. 

Methods  of  Replacement. 

Manipulation. — Diseased  adnexse,  especially  salpingitis,  contra- 
•indicate  forcible  manipulations  of  the  })elvic  organs.  The  dangers 
incident  to  stretching  or  breaking  adhesions  or  contractions  are  very 
great  unless  the  manipulator  possesses  unusual  diagnostic  and  manual 
skill.  The  safest  and  most  effective  method  of  replacement  is  by  con- 
joined manipulations,  as  shown  in  the  following  illustrations.  Effi- 
cient reposition  of  the  uterus  is  very  often  impossible  without  anaes- 
thesia. This  is  especially  true  when  the  corpus  is  wedged  in  and 
incarcerated  between  the  uterosacral  ligaments  under  the  sacral  prom- 
ontory, a  condition  often  mistaken  for  displacement  with  adhesions. 

The  replacement  is  not  usually  accomplished  by  drawing  the  fundus 
directly  forward  and  pushing  the  cervix  back  directly  in  the  median 
line,  but  in  most  cases  by  sweeping  the  fundus  around  the  arc  of  a 
circle  on  the  left  side  of  the  pelvis  and  the  cervix  on  the  right.  This 
is  owing  to  the  greater  frequency  of  infection  on  the  left  side,  and 
consequent  shortening  of  the  left  broad  ligament.  After  replacement 
the  organ  is  to  be  held  in  position  by  appropriate  means. 

Bimanual  replacement  has  three  great  advantages  over  the  more 
familiar  methods  of  the  sound  or  repositor:  first,  it  is  more  effective 
and  more  permanent ;  second,  the  lever  action  of  the  sound  or  repositor, 
by  which  the  operator  may  unwittingly  use  an  undue  and  dangerous 
amount  of  force,  is  avoided  in  the  use  of  the  hand ;  third,  the  ope- 
ration is  not  only  constantly  under  the  operator's  control,  but  also 
within  his  appreciation.  Experience  has  abimdantly  shown  that  instru- 
mental uterine  reposition  by  means  of  the  sound  or  other  instruments 
which  enter  the  endometrium,  and  act  by  leverage,  is  unnecessary^ 
dangerous,  and  therefore  usually  disapproved. 

Brandt  Method. — Manipulation  has  some  value  in  overcoming  the 
obstacles  to  replacement  and  has  well-defined  value  in  the  replacement 
of  a  uterus.  The  manipulations  described  below  are  those  of  Brandt. 
The  methods  of  Brandt  involve  much  complicated  massage  and 
various  gymnastic  movements,  and  are  available  only  to  the  specially 
trained  expert ;  besides,  for  obvious  reasons,  when  long  continued  they 
would  be  regarded,  at  any  rate  in  this  country,  as  somewhat  objection- 
able even  though  entrusted  to  a  masseuse.  The  author  has  no  per- 
sonal experience  in  the  administration  of  this  form  of  treatment,  nor 
has  he  been  able  usually  to  command  the  services  of  a  competent  and 
satisfactory  masseuse.  Certain  manipulations  of  the  Brandt  system, 
however,  apart  from  the  local  massage  and  the  associated  gymnastic 
movements,  are  adapted  to  the  detection  of  intrapelvic  lesions,  and 
therefore  are  set  forth  here  partly  for  their  diagnostic  value,  but  they 
are  presented  more  especially  for  their  value  in  the  replacement  of  the 
retroposed  uterus. 

Manipulation  in  the  Treatment  of  Retroposition  Complicated  by 
Anterior  Adhesions  and  Contractions, — A  serious  obstacle  to  replace- 
ment and  retention  of  a  retroposed  uterus  is  the  presence  of  contracted 
tissue  between  the  cervix  uteri  and  the  pubes,  which  antelocates  the 
cervix  to  such  to  extent  that  the  corpus  has  space  to  fall  back  under 
the  sacral  promontory.     Under  such  conditions  the  corpus  cannot  be 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.     677 
Figure  369. 


Stretching  adhesions  anterior  to  the  uterus. 
Figure  370. 


Resisting  anterior  attachments.  Dorsal  position :  intravaginal  finger  pushes  cervix  down- 
,™  ""^^  backward;  corpus  thrown  forward  on  its  transverse^  axis  fright  hand  draws  corpus 
upward  and  forward  by  exerting  force  through  abdominal  wall.  corpus 

41 


678 


DISPLA  CEMENTS. 


brought  forward  and  retained  in  normal  anteversion  until  the  con- 
tracted tissue  or  bands  which  hold  the  cervix  forward  can  be  so 
stretched  or  broken  as  to  permit  the  cervix  to  return  to  its  normal 
location  near  the  hollow  of  the  sacrum  ;  this  may  sometimes  be  ac- 
complished by  manipulation  if  the  adhesions  and  contracting  bands 
are  not  too  strong.  Several  weeks  of  treatment  may  be  required  to 
obtain  the  desired  result.  The  manipulations  of  anterior  adhesions, 
shown  in  Figures  369  and  370,  are  as  follows : 

The  left  index-finger  is  introduced  first  back  of  the  cervix  and  the 
body  of  the  uterus  is  raised  as  far  as  practical  in  the  median  line. 
The  intravaginal  finger  is  then  transferred  to  the  front  of  the  cervix, 
while  the  external  hand  readily  pushes  the  uterus  backward,  so  as  to 
move  it  aAvay  from  the  symphysis  and  still  further  stretch  or  break 
the  adhesions.  By  pressing  the  fingers  of  the  external  hand  down 
behind  the  symphysis  they  are  made  to  meet  the  intravaginal  fingers 
in  front  of  the  uterus.  The  fingers  of  the  two  hands  thus  brought 
together  then  push  the  uterus  in  the  following  directions :  the  internal 
fingers  backward  and  upward,  the  external  fingers  backward  and 
downward.  This  manipulation  should  not  be  carried  beyond  a  certain 
limit  to  the  ready  extension  of  the  tissues. 

Manipulation  in  the  Treatment  of  Retroposition  Complicated  by  Pos- 
terior Adhesions  and  Contractions. — Posterior  adhesions  and  contrac- 

FlGUEE  371. 


stretching  or  breaking  posterior  adhesions. 

tions  may  be  stretched  and  broken  on  the  same  principles  and  by  the 
same  manipulations  as  those  already  set  forth  for  anterior  adhesions 
and  contractions.     Figure  371. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.     679 

Replacement  and  Retention  of  the  Retroposed  Uterus. 

When  the  uterus  is  mobile  and  not  too  sensitive,  replacement  and 
retention  in  the  normal  position  are  indicated,  and  may  be  accom- 
plished in  the  manner  set  forth  in  the  following  text  and  illustrations. 

Manual  Ventrovaginal  Reposition  of  the  Retroposed  XJterus. 

Figures  372-376  taken  together  will  explain  an  efficient  method 
of  replacing  a  retroposed  uterus.  The  left  index-finger,  in  the 
posterior  vaginal  fornix  as  high  as  possible,  raises  the  uterus  toward 
the  abdominal  wall — Figures  372  and  373 — while  the  fingers  of  the 
right  hand  above  the  symphysis  press  down  on  the  cervix,  the  point 
of  pressure  being  as  nearly  as  possible  the  plane  of  the  internal  os, 

Figure  372. 


Ventrovaginal  reposition ;  beginning  of  first  step. 

Figure  374.  The  left  index-finger,  then  leaving  the  posterior,  passes 
to  the  anterior  fornix  and  approaches  the  fingers  of  the  right  hand, 
Figure  375.  Both  hands,  acting  together,  push  the  cervix  upward 
and  backward,  while  the  uterus  tends  to  fall  over  slightly  forward. 
Then,  while  the  left  index-finger  is  kept  fixed,  the  fingers  of  the 
right  hand  are  passed  lightly  along  the  right  border  of  the  uterus 
until  they  pass  the  fundus,  which  they  then  press  forward.  Figure 
376.  The  organ  then  lies  extended  along  the  left  index-finger.  It 
is  essential  for  the  success  of  this  manoeuvre  that  the  uterus  be  kept 
in  the  median  line,  or  that  in  the  replacement  it  be  swung  around 
slightly  to  the  left.  Reposition  may  be  facilitated  by  exerting  traction 
on  the  uterus  by  means  of  a  vulsella  forceps  during  the  manipulation, 
Figure  14. 


680 


DISPLA  CEMENTS. 
FiGUEE  373. 


Ventrovaginal  reposition ;  end  of  first  step. 


Figure  374. 


Ventrovaginal  reposition ;  second  step. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.     681 
Figure  375. 


Ventrovaginal  reposition ;  third  step. 


FiGxjBE  376. 


Ventrovaginal  reposition ;  final  step. 


682 


DISPLA  CEMENTS. 
FiGUBE  377. 


Ventro-rectovaginal  reposition ;  first  step. 
FiGUKE  378. 


Ventro-rectovaginal  reposition  r  second  step. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.     683 

Manual  Ventro-rectovaginal  Reposition  of  the  Retroposed  Uterus. 

This  method  of  replacement  is  illustrated  by  Figures  377—379. 
The  left  index-finger,  high  up  in  the  rectum,  pushes  the  fundus  for- 
ward, while  the  right  hand  on  the  abdomen  executes  some  circular 
and  vibratory  movements.  As  the  muscles  relax,  the  external  fingers 
approach  the  fundus  and  push  it  downward,  so  that  it  may  readily  be 
reached  by  the  finger  in  the  rectum ;  this  finger  is  aided  by  the  thumb 
in  the  vagina  pressing  the  cervix  backward.  The  fingers  of  the  right 
hand,  continuing  the  circular  movements,  then  insinuate  themselves  be- 
hind and  under  the  fundus,  and  complete  the  replacement.    Figure  379. 

Figure  379. 


Ventro-rectovaginal  reposition  ;  final  step. 
Figures  365-375  and  the  explanatory  text  are  modified  from  Jentzer  and  Zeegenspeck. 

The  degree  to  which  the  manipulations  are  necessary  will  depend 
upon  the  breadth  and  strength  of  the  adhesions  and  bands,  and  the 
amount  of  contraction  in  the  ligaments.  AU  manipulations  should  be 
practised  only  on  cases  carefulli/  selected  according  to  the  indications 
and  contraindications  set  forth  in  the  beginning  of  this  chapter,  and 
should  be  as  gradual  and  as  free  from  pain  as  practicable. 

The  length  of  time  that  should  elapse  after  an  acute  inflammation 
before  manipulative  reposition  may  be  undertaken  with  safety  is  not 
less  than  two  months,  Pyosal])inx  is  always  a  contraindication.  The 
nearer  the  time  to  an  acute  infection  the  more  virulent  the  pus  will 
be ;  and,  on  the  contrary,  the  longer  the  time  the  more  likely  the  pus 


684 


DISPLA  CEMENTS. 


is  to  be  sterile.  If,  therefore,  oh  account  of  error  in  diagnosis  the 
manipulative  movements  should  rupture  a  purulent  tube  and  force 
the  contents  of  it  into  the  abdomen,  the  danger  of  peritoneal  infection 
would  be  decreased  directly  with  the  length  of  time  that  had  elapsed 
since  the  acute  attack. 


Means  to  Retain  the  Replaced  Uterus. 

The  uterus  having  been  replaced  will  seldom  retain  its  normal 
position  without  artificial  support.  This  support,  according  to  the 
requirements  of  a  given  case,  will  be  secured  by  means  of 

1.  Pessaries.  2.  Surgical  operations. 

1.  Eetentiox  by  Pessaries. 

Contraindications  and  Indications  to  the  Pessary. 

The  enthusiast  in  mechanical  gynecology  would  do  well  to  consider 
the  four  following  propositions  : 

Figure  380. 


The  common  but  faulty  mode  of  introducing  a  pessary,  with  its  breadth  turned  in  the 
anteroposterior  diameter  of  the  vulva.  The  breadth  of  the  instrument  should  be  in  the  trans- 
verse direction,  as  shown  in  Figure  381. 

1.  In  the  majority  of  cases  of  retrodisplacement  the  essential  factor 
is  inflammation,  and  the  resultant  tenderness  may  render  mechanical 
support  intolerable. 


TREATMENT  OF  RETROVERSION  AND   RETROFLEXION.     685 


2.  Adhesions  and  cicatricial  bands  may  prevent  or  prohibit  replace- 
ment, and  therefore  contraindicate  the  use  of  any  means  designed  to 
hold  the  organ  in  place, 

3.  A  tumor  or  excessive  weight  of  the  uterus  may  carry  the  corpus 
backward  and  downward  with  a  force  greater  than  any  pessary  can 
counteract. 

4.  The  pelvic  floor,  including  the  fascial  and  ligamentous  supports 
of  the  pelvic  organs,  may,  from  subinvolution  or  other  cause,  be  so 
relaxed  that  no  pessary  can  hold  the  organs  in  place. 

It  follows  from  the  above  that  the  field  for  the  use  of  the  pessary 
must  be  restricted  to  those  cases  in  which  the  displaced  organs  are 
replaceable,  and  in  which  the  pessary  is  capable  of  holding  them  in 
place,  and  can  be  worn  without  discomfort.  Failure  to  recognize  and 
appreciate   the  contraindication    accounts    not  only  for   the  failures 

Figure  381. 


A,  the  correct  mode  of  introducing  a  pessary.    B,  section  through  pelvis  shows :  V,  urethra; 
V,  vagina ;  R,  rectum ;  L  V,  levator  ani  muscle. 

and  disappointments,  but  also  for  the  many  evil  results  which  have 
followed  indiscriminate  attempts  to  treat  all  displacements  by  me- 
chanical support.  The  exclusion  of  unsuitable  cases  and  the  recog- 
nition of  the  necessity  for  accurate  diagnosis  are  apparent.  The 
pessary,  according  to  the  knowledge,  judgment,  and  mechanical  skill 
of  the  practitioner,  will  be  useful,  useless,  or  injurious. 


686 


DISPLACEMENTS. 


The  Function  of  the  Pessary. 

The  function  of  the  pessary  is  to  maintain  the  uterus  not  only  on 
the  health  level  in  its  normal  location,  but  also^  if  possible,  in  its 
normal  position,  which  requires  the  cervix  to  be  about  one  inch  from 
the  hollow  of  the  sacrum.  The  cervix  in  a  properly  selected  case 
being  thus  placed,  retroversion  is  not  liable  to  occur,  because  if  it  does 
occur  the  fundus  uteri  will  be  arrested  in  its  backward  course  by  the 
over-arching  sacrum,  and  because  the  direction  of  least  resistance  will 
be  forward  into  the  normal  anterior  position. 

Figure  382. 


The  upper  end  of  an  Albert  Smith  pessary  being  pushed  into  place  back  of  the  cervix  uteri. 
The  apparent  lack  of  mobility  at  the  normal  angle  of  flexure  in  this  uterus  is  a  not  uncom- 
mon result  of  the  metritis  which  often  complicates  retroversion  and  retroflexion. 

It  follows  that  the  application  of  the  pessary  is  based  upon  the 
general  proposition  that  if  the  cervix  be  normally  j)laced  the  body  of  the 
uterus,  in  the  absence  of  complications,  will  take  care  of  itself.  Since  the 
vagina  at  its  up])er  extremity  is  attached  to  the  cervix,  displacement 
of  the  latter  is  clearly  impossible  if  the  upper  extremity  of  the  vagina 
be  sustained  in  its  normal  location.  The  pessary  restores  and  main- 
tains the  relations  of  the  relaxed  vaginal  walls  by  crowding  the  poste- 
rior vaginal  cul-de-sac  backward  into  the  hollow  of  the  sacrum.     It 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION     687 

also  holds  the  attached  cervix  at  a  proper  distance  from  the  sacrum, 
and  thereby  fulfils  its  indication  by  sustaining  the  pelvic  floor.  The 
Hodge  pessary,  or  some  modification  thereof,  answers  this  purpose  in 
ordinary  cases  more  satisfactorily  than  any  other. 

The  same  general  principles — in  fact,  the  same  pessaries — which 
are  applicable  to  prolapse  apply  also  to  retroversion  and  retroflexion, 
because  the  first  step  in  the  genesis  of  retro-malpositions  is  prolapse. 

Pessaries  designed  to  prop  up  the  body  of  the  uterus  by  pressure 
upon  the  posterior  wall  for  the  correction  of  posterior  malpositions,  and 
upon  the  anterior  wall  to  correct  anterior  malpositions,  are  not  only 
unnecessary,  but  they  are  also  very  liable  to  induce  metritis  and  peri- 
metritis, and  therefore  are  disapproved  generally.  In  certain  cases, 
however,  the  vaginal  vv^alls,  especially  the  posterior,  may  ])e  so  relaxed 
from  subinvolution  and  other  causes  that  the  instrument,  though  very 

Figure  383. 


Albert  Smith  pessary  in  place  and  uterus  maintained  in  normal  position. 

long,  fails  to  maintain  the  cervix  in  its  normal  place.  Under  such 
conditions  an  instrument  may  be  required  to  act  directly  upon  the 
uterus.  The  Schultze  sleigh  pessary,  although  seldom  indicated, 
represented  in  Figure  386,  fulfils  this  indication.  A  long  Albert 
Smith  pessary,  with  its  uterine  curve  made  so  extreme  as  to  liring  the 
upper  part  of  the  instrument  in  front  of  the  cervix,  instead  of  behind, 
may  answer  the  same  purpose.  Expedients  of  this  kind,  however, 
are  always  of  doubtful  value. 


688 


BIS  PL  A  CEMENTS. 


Adjustment  of  the  Pessary. 

Figure  380  shows  a  common  but  faulty  manner  of  introducing  the 
pessary.  The  vagina  is  a  collapsed  tube,  the  anterior  walls  of  which 
rest  on  the  'posterior ;  hence,  the  long  diameter  of  a  cross-section  of 
the  canal  is  from  side  to  side,  not  anteroposterior.  The  pessary 
should,  therefore,  be  introduced  with  its  lateral  edges  to  the  sides  of 
the  vulva. 

If  introduced  as  shown  in  Figure  380,  with  its  lateral  edges  in  the 
anteroposterior  direction  of  the  vulva,  the  pessary  is  apt  to  press 
painfullv  against  the  urethra  in  front  and  the  perineum  behind.  This 
pain  is  increased  when  the  instrument  is  turned  to  conform  to  the 
shape  of  the  vagina,  as  it  must  be  before  it  can  take  its  proper  place. 

In  the  correct  mode  of  introduction  the  labia  are  separated  by  the 
thumb  and  index-finger  of  the  left  hand,  and  the  pessary  is  pushed 
in  with  the  right  hand,  its  lateral  edges  being  to  the  sides  of  the 
vulva ;  it  then  readily  follows  the  curve  of  the  vaginal  outlet.  This 
mode  of  introduction  requires  less  force  and  gives  less  discomfort. 
The  first  step  toward  adjustment  is  complete  when  the  inner  end  of 
the  pessary  is  in  contact  with  the  anterior  wall  of  the  cerv^ix  uteri. 
The  second  step  is  to  pass  the  left  index-finger,  the  palmar  surface 
being  in  contact  with  the  perineum,  under  the  pessary,  and  push  the 
upper  end  under  the  cervix  and  then  backward  into  its  place  in  the 
post-vaginal  fornix.     See  Figures  381,  382,  and  383. 

The  curves  of  the  pessary  demand  careful  attention  in  its  applica- 
tion. Wlien  the  uterus  is  below  the  normal  level,  the  broad  ligaments 
necessarily  are  rendered  more  tense  than  natural,  and  the  bloodvessels, 
more  especially  the  veins,  which  are  looped  one  upon  the  other,  and 
which  traverse  these  ligaments  to  and  from  the  uterus,  are  made  to 
collapse.  This  causes  venous  congestion  and  consequent  increase  in 
weight  of  the  uterus — a  condition  favorable  to  malposition,  uterine 
catarrh,  and  pathological  changes  in  structure.  A  pessary  which  will 
raise  the  uterus  to  the  health  level  clearly  fulfils  an  indication.     A 


FiGUBE  384. 


FlGUKE  385. 


The  Emmet  curves. 


The  Albert  Smith  curves. 


pessary  which  raises  it  above  the  health  level  renders  the  broad  liga- 
ment tense  and  reproduces  a  condition  which  it  was  designed  to  relieve. 
Maintenance  of  the  uterus  upon  the  health  level  depends  largely  upon 
the  curves  of  the  pessary.  The  accompanying  cuts  illustrate  the  shape 
and  curve  of  the  Hodge  pessary  as  modified  by  Emmet  and  Albert 
Smith.     Figure  384  represents  the  curves  of  Emmet,  and  Figure  385 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.    689 

those  of  Albert  Smith.  For  convenience,  let  us  characterize  that  curve 
which  rests  in  the  posterior  vaginal  cul-de-sac  as  the  uterine  curve, 
and  that  which  occupies  the  part  of  the  vagina  adjacent  to  the  pubis 
the  pubic  curve.  The  acuteness  and  length  of  the  uterine  curve 
determine  the  height  to  which  the  pessary  will  lift  the  uterus.  The 
longer  and  more  acute  the  curve,  the  higher  the  uterus  will  be  lifted, 
and  vice  versa.  The  smaller  curve  of  the  Emmet  modification  will 
answer  the  average  indication  more  nearly  than  the  sharper  curve  of 
the  Albert  Smith  modification,  which  may  lift  the  uterus  too  high. 
The  pubic  should  generally  be  proportioned  to  the  uterine  curve — 
that   is,  the  greater  the   uterine,  the  greater  the  pubic    curve.     A 

Figure  386. 


Schultze's  sleigh  pessary  in  position.    This  pessary  is  not  in  general  use,  but  is  serviceable  to 
hold  up  the  yesicovaginal  wall  in  cases  of  cystocele  and  rectocele. 

pessary  properly  adjusted  in  all  other  respects  may,  by  pressure  upon 
the  urethra  and  neck  of  the  bladder,  create  vesical  tenesmus  and  ure- 
thral irritation.  This  calls  for  increase  in  the  pubic  curve — that  is, 
the  pessary  should  be  bent  away  from  the  irritated  part.  The  pubic 
curve  may,  however,  be  so  great  that  the  lower  part  of  the  pessary 
occupies  the  centre  of  the  vulva,  where  it  is  apt  to  create  irritation. 
For  this  condition  lessening  of  the  pubic  curve  is  the  remedy.  The 
pessary  should  not  be  so  wide  as  to  distend  the  vagina.  The  length 
should  be  measured  by  the  distance  from  the  lower  extremity  of  the 
symphysis  pubis  to  the  posterior  vaginal  cul-de-sac,  less  the  thickness 


690  .  DISPLACEMENTS. 

of  the  finger.  If  properly  adjusted  in  a  suitable  case,  it  should  sus- 
tain the  pelvic  floor  in  its  normal  relations  and  the  uterus  in  stable 
equilibrium. 

Thomas"  retroflexion  pessary,  with  its  bulbous  upper  extremity,  is 
a  long,  narrow  instrument  of  extreme  uterine  curve.  It  lifts  the 
uterus  very  high,  and  is  specially  applicable  in  cases  of  great  relaxa- 
tion of  the  pelvic  floor  and  of  complicating  prolapse  of  the  ovaries : 
sometimes  the  bulbous  portion  is  made  of  soft  rubber. 

FiGimE  387, 


Thomas'  retroflexion  pessary. 

In  retroversion  and  retroflexion  always  replace  the  uterus  before 
adjusting  the  pessary,  otherwise  the  instrument  will  press  upon  the 
sensitive  uterus,  and  one  of  three  unfortunate  results  may  occur :  (a) 
the  pessary  may  not  be  tolerated  on  account  of  pain ;  (6)  it  may  be 
forced  down  by  pressure  from  above  so  near  to  the  vulva  that  it  will 
fed  to  do  the  least  good;  (e)  the  uterus,  finding  it  impossible  to  hold 
its  position  against  the  pessary,  instead  of  taking  its  proper  position, 
may  be  bent  over  it  in  exaggerated  retroflexion,  with  the  cervix  be- 
tween the  pessan^  and  the  pubes,  or  the  whole  organ  may  slip  off  to 
one  side  of  the  instrument  into  a  malposition  more  serious  than  the 
one  for  which  relief  is  sought. 

_A  properly  adjusted  pessary  gives  to  the  patient  no  consciousness 
of  its  presence.  If  the  instrument  causes  ])ain,  it  should  be  removed, 
and  search  made  for  the  tender  places  ;  it  then,  if  possible,  should  be 
remoulded  into  such  shape  that  it  will  not  make  pressure  upon  them. 
In  remoulding  a  hard  rubber  pessarv.  one  should  pass  it  rapidlv  back 
and  forth  through  the  flame  of  a  spirit  lamp  until  it  is  sufficiently 
softened  to_  be  bent  to  the  desired  form.  Often  a  slight  indentation 
at  some  point  will  enable  the  patient  to  wear  it  with  comfort.  If  it 
cannot  be  made  comfortable,  it  should  be  abandoned. 

Sometimes  when  the  corpus  has  been  firmly  bound  back  bv  peri- 
toneal adhesions  they  may  be  broken  up  bv  verv  forcible  conjoined 
manipulation  under  ether  ;  but  the  operation  is  dano-erous,  and  should 
therefore  be  undertaken  only  by  an  expert  operatorfif  at  all. 

In  certain  cases  in  which  replacement  is  impracticable  or  impossi- 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.     691 

ble,  on  account  of  inflammation  or  adhesions,  a  soft  rubber  ring  may 
be  inserted,  and  will  sometimes  give  decided  relief  by  lifting  the 
uterus  and  pelvic  floor  nearer  to  the  health  level.  In  the  treatment 
of  all  displacements  coition  should  be  forbidden  until  the  inflamma- 
tory signs  have  disappeared.  The  pessary  should  be  kept  clean  by 
moderate  daily  applications  of  the  vaginal  douche.  Every  three  or 
four  weeks  the  instrument  should  be  removed  and  the  pelvic  organs 
carefully  examined. 

No  one  can  safely  apply  the  pessary  until  he  has  fully  appreciated 
its  indications  and  contraindications.  Many  practitioners  are  deficient 
in  the  natural  mechanical  skill  necessary  to  its  proper  adjustment — a 
fact  of  which  thousands  of  unfortunate  women  bear  witness.  Its 
dangers  in  inefficient  hands  are  in  striking  contrast  with  its  usefulness 
when  judiciously  employed  in  proper  cases. 

2.  Eetention  by  Suegical,  Opeeations. 

Many  cases  of  displacement  are  so  complicated  by  prolapsed  and 
adherent  ovaries,  by  advanced  disease  of  the  ovaries  and  Fallopian 
tubes,  by  tumors,  by  inflammatory  exudates,  or  by  peritoneal  adhe- 
sions, that  replacement  is  impossible,  or,  replacement  being  possible, 
the  pessary  is  either  intolerable  from  pain  or  proves  inadequate  to 
sustain  the  uterus.  Such  cases,  unless  relievable  by  non-surgical 
measures,  furnish  a  definite  indication  for  surgical  treatment. 

Perineorrhaphy,  eli/trorrhaphy,  and  the  removal  of  tumors  may  be 
necessary,  and  have  been  considered  under  their  respective  heads. 
Whenever  the  perineum  has  been  displaced  downward  and  backward 
away  from  the  pubes  toward  the  coccyx,  its  restoration  by  perineor- 
rhaphy or  by  some  suitable  plastic  operation  upon  the  vaginal  outlet 
is  always  indicated  ;  see  Chapters  XL.  and  XLI.  Elytrorrhaphv  is 
not  usually  indicated  unless  the  retro-malposition  is  associated  with 
descent  to  the  second  or  third  degree.  If  the  malposition  is  caused  by 
a  tumor,  the  pathology,  diagnosis,  prognosis,  and  treatment  will  be 
those  of  the  tumor. 

The  surgical  treatment  proper  of  posterior  malpositions  involves 
especially  a  description  and  comparison  of  the  three  most  recognized 
classes  of  operations.  Each  has  its  special  adaptation  to  its  own  class 
of  cases.  In  the  treatment  of  some  cases,  according  to  the  individual 
preference  of  the  surgeon,  either  one  of  the  three  is  permissible.  The 
operations  are  : 

1.  Alexander's  operation,  shortening  the  round  ligament.^ 

2.  Abdominal  hysterorrhaphy. 

3.  Vaginal  hysterorrhaphy. 

Alexander's  Operation. 

The  round  ligaments,  as  already  explained,  restrain  the  uterus  from 
excessive  backward  movement.  They  are  two  cords,  each  the  size  of 
a  goose-quill,  springing  from  the  horns  of  the  uterus,  just  below  and  in 

1 A  verv  full  paper  on  this  subject  is  one  by  George  M.  Edebohls,  in  the  American  Gj^necO" 
logical  and  Obstetrical  Journal,  December.  1896.  This  paper  contains  an  exhaustive  bitUiog- 
Taphy. 


692  DISPLACEMENTS. 

front  of  the  origin  of  the  Fallopian  tube.  They  pass  forward  on  either 
side  in  the  folds  of  the  broad  ligaments  through  the  internal  inguinal 
rino-s,  through  the  inguinal  canals  and  the  external  rings,  and,  spread- 
ing out  in  strands,  are  lost  in  the  mons  veneris  and  upper  parts  of  the 
labia  majora.  These  ligaments  consist  of  unstriped-  muscular  fibres  in 
condensed  areolar  tissue.  Physiologically  they  have  some  contractile 
power. 

When  the  uterus  is  retroposed,  the  round  ligaments  are  neces- 
sarily stretched  to  such  an  extent  that  they  can  no  longer  exert  their 
normal  restraining  power  upon  the  backward  movements  of  the 
organ ;  hence  the  proposition  of  Alexander  to  shorten  them  extra- 
peritoneally  to  such  an  extent  that  they  will  resume  their  normal 
functions.     This  is  Alexander's  operation. 

Indications  and  Contraindications  for  Alexander's  Operation. 

This  operation  is  permissible  only  when  the  displacement  is  not  com- 
plicated by  a  tumor,  inflammation  of  the  uterine  appendages,  adhesions, 
or  other  impediments  to  replacement.  Clearly,  shortening  the  liga- 
ments could  not  hold  in  place  a  uterus  firmly  bound  down  by  adhe- 
sions or  weighted  down  by  a  tumor.  True,  as  some  advise,  the 
peritoneal  cavity  might  be  opened  and  the  adhesions  broken  up  or  the 
tumor  removed,  as  preliminary  measures  to  the  shortening  of  the 
ligaments ;  but  under  such  conditions  most  surgeons  would  prefer 
suspension  of  the  uterus  by  hysterorrhaphy  as  being  the  more  rational 
and  effective  operation.  If  the  uterus  can  be  retained  in  place  by  a 
pessary,  or  can  be  tre^ed  successfully  by  massage,  or  by  any  of  the 
other  non-operative  means  already  described,  Alexander's  operation, 
though  not  a  procedure  of  necessity,  may  yet  be  one  of  expediency. 
The  expediency  will,  however,  depend  upon  the  woman's  ability  and 
willingness  to  carry  out  the  more  conservative  course.  Temporizing 
measures  may  insure  comfort  only  so  long  as  she  can  be  free  from 
care,  anxiety,  and  overwork.  If  she  must  earn  her  living,  a  radical 
cure  by  surgical  measures  may  be  necessary.  After  ansesthesia,  before 
the  operation  is  begun,  a  thorough  conjoined  examination  should 
always  be  made,  in  order  especially  to  exclude  inflammation  of  the 
uterine  appendages ;  this  is  because  the  operation,  if  made  in  the 
presence  of  unsuspected  suppuration  in  the  tube  or  ovary,  may  lead 
to  fatal  peritonitis. 

Preparatory  Treatment  for  Alexander's  Operation. 

The  preparatory  treatment  is  the  same  as  that  laid  down  in  Chapter 
11. ,  for  abdominal  and  vaginal  section.  Endometritis  is  almost  always 
present  in  the  retroposed  uterus  ;  hence  dilatation  and  curettage  are 
indicated,  and  should  be  performed  immediately  before  the  shortening 
of  the  ligaments  ;  the  reason  for  this  is  twofold  :  first,  to  cure  the  endo- 
metritis ;  second,  to  render  the  endometrium  aseptic,  and  thereby  shut 
off  post-operative  infection  from  that  source.  Necessary  plastic  opera- 
tions on  the  cervix  uteri,  vagina,  and  perineum  may,  according  to  the 
strength  of  the  patient  and  the  rapidity  and  dexterity  of  the  operator, 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.    693 

be  made  at  the  same  time.     If  the  perineum  is  iujured,  its  repair  is 
essential  to  success. 

Steps  of  Alexander's  Operation. 

The  steps  of  the  operation  are  :  1.  To  find  and  isolate  the  ligaments. 
2.  To  draw  them  out  until  their  superabundant  slack  has  been  taken 
up.  3.  To  anchor  or  fix  the  drawn-out  portions  by  means  of  suture, 
in  order  to  keep  them  from  slipping  back  into  the  pelvic  cavity  through 
the  internal  ring.  The  location  and  extent  of  the  incision  and  the  mode 
of  isolation  of  the  ligaments  vary  with  different  operators.  For  exam- 
ple, an  incision  direct  to  the  internal  ring  was  practised  first  by  Alex- 
ander ;  ^  it  is,  however,  often  difficult  to  find  the  ligaments  at  this  point. 
J.  Frank  and  Newman  ^  cut  directly  to  the  internal  ring.  Kellogg 
opens  tlie  inguinal  canal  by  a  small  incision  near  the  internal  ring. 
Edebohls  opens  the  canal  throughout  its  entire  length.  The  method 
of  Kellogg,  with  minor  modifications,  is  the  one  adopted  by  the  writer, 
and  is  substantially  as  follows  :  ^ 

Anatomical  Landmarks  for  Alexander's  Operation. 

The  superficial  anatomical  landmarks  are  the  anterior  superior 
spine  of  the  ilium,  the  spine  of  the  pubes,  and  Poupart's  ligament. 
The  deeper  landmarks  on  either  side  are  the  external  inguinal  ring, 
which  lies  just  above  the  spine  of  the  pubes ;  the  internal  ring,  about 
three  inches  above,  in  the  direction  of  the  anterior  superior  spine  of 
the  ilium  ;  and  the  inguinal  canal,  which  lies  between  the  internal  and 
external  rings  ;  and  the  rings  form  the  ends  of  the  canal. 

The  Incision  for  Alexander's  Operation. 

The  incision  through  the  skin  is  made  midway  between  the  internal 
and  external  rings,  one  inch  or  more  long,  parallel  to  and  just  above 
Poupart's  ligament;  this  is  directly  over  the  middle  third  of  the  roof 
of  the  canal.  A  clean  and  careful  dissection  is  now  made  to  the  ten- 
don of  the  external  oblique  muscle.  It  is  important  that  the  natural 
color  and  appearance  of  the  cut  surfaces  be  preserved,  in  order  that 
the  exact  point  of  incision  into  the  canal  may  be  readily  recognized ; 
hence  the  necessity  of  clean  dissection  and  immediate  control  of  all 
bleeding  points  by  snap-forceps. 

The  glistening  tendon  of  the  external  oblique  now  exposed  usually 
will  show  a  dark  line.  This  line  marks  a  point  where  the  fibres  of 
the  tendon  begin  to  separate  to  form  the  columns  of  the  external 
ring.  The  borders  of  the  separated  tendon  are  connected  by  the 
intercolumnar  fascia,  which,  being  thinner  than  the  tendon,  enables  one 
to  see  through  it  to  the  darker  tissues  beneath.  There  maybe  several 
narrow  points  of  separation  or  one  broad  one.  In  exceptional  cases 
the  separation  is  absent  up  to  the  very  border  of  the  external  ring. 
"When  the  dark  line  has  been  found,  pass  the  finger  down  the  line 

1  Alexander.    London :  ChurchiU,  1884.    Hart  and  Barbour, 
s  American  Journal  of  Obstetrics,  1888. 

»  The  description  here  given  is  in  the  main  an  extract  from  the  paper  of  Kellogg ;  reprint 
from  the  Proceedings  of  the  Michigan  State  Medical  Society,  1898. 

42 


694 


DISPLA  CEMENTS. 


toward  the  pubic  spine,  and  see  that  it  opens  into  the  external  ring. 
This  locates  the  canal.  The  wound  is  now  drawn  widely  open  by  two 
retractors  in  the  hands  of  an  assistant.  The  opening  in  the  tissues, 
overlying  the  tendon,  thus  widely  separated  may  be  slid  about  over  a 
considerable  area  until  the  right  point  for  opening  the  canal  is  found ; 
it  is  about  three-quarters  of  an  inch  below  the  internal  ring.  At  this 
point  a  puncture  or  an  incision,  not  more  than  a  third  of  an  inch  long, 
is  made  by  a  small  scalpel  through  the  tendon. 

Finding  the  Ligament  in  Alexander's  Operation. 

To  find  the  ligament,  take  two  small  hooks,  Figure  389,  one  in 
each  hand.  The  small  opening  is  made  to  gape  with  the  hook 
in  the  left  hand,  while  the  other  is  passed  by  the  right  hand  into 
the  opening  and  directly  backward,  the  flat  side  of  the  hook  parallel 


FiorRE  388. 


Figure  389. 


Two  of  these  retraftors  are  needed  for 
opening  the  wound. 
Full  length,  6  inches. 


Two  of  these  hooks  are  needed  for 

picking  up  the  round  ligament. 

Full  length,  6  inches. 


to  Poupart's  ligament  and  hugging  it  closely.  When  the  hook  has 
penetrated  to  a  depth  of  about  one  inch,  its  point  is  turned  toward 
the  canal,  and  the  tissues  that  come  in  its  way  are  hooked  by  a  wide 
sweep  and  drawn  up  through  the  slit  in  the  roof  of  the  canal.     The 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.     695 

little  mass  of  tissue  thus  brought  up  will  often  contain  the  ligament, 
but  more  frequently  it  is  just  below  the  hook  and  closely  connected 
with  the  tissue  engaged  by  the  hook.  A  dip  with  the  other  hook  will 
bring  up  the  ligament  itself.  The  tissue  thus  brought  into  view-  is  a 
grayish-colored  mass  of  fat,  which  contains  anastomosing  blood-vessels 
and  the  ligament,  with  its  accompanying  ilio-inguinal  nerve  and  vessels. 
The  operator  who  attempts  to  find  the  ligament  as  Alexander 
directed,  by  cutting  down  through  the  mass  of  fat,  will  find  himself 
embarrassed  by  the  resultant  bleeding  and  the  disarrangement  of  the 
contents  of  the  canal.  He  may  for  hours  grope  blindly  about  the 
region  among  a  variety  of  structures  which  marvellously  resemble, 
but  are  not,  the  ligament.^  The  earlier  operators,  who  cut  directly  to 
the  external  ring,  where  the  ligament  spreads  out  just  before  passing, 
fan-shaped,  to  the  pubes  and  labia,  frequently  were  misled,  and  there- 
fore often  unsuccessful. 

Drawing  Out  the  Ligaments  in  Alexander's  Operation. 
The  mass,  having  been  picked  up  by  the  hook,  is  now  spread  out 
on  the  finger,  and  the  ligament,  invested  in  its  fascial  sheath,  is  recog- 

FlGURE  390. 


d,  the  internal  ring ;  c,  external  ring ;  light  dotted  lines  between  indicate  the  position  of  the 
inguinal  canal,  the  heavy  dotted  lines  below  indicate  the  direction  of  Poupart's  ligament. 
a  shows  position  of  skin  incision  ;  e,  e,  indicate  retractqrs  by  which  the  tissues  divided  by  the 
incision  are  separated  down  to  the  tendon  of  the  external  oblique  ;  6  shows  the  small  incision 
in  the  tendon  of  the  external  oblique  near  the  internal  ring ;  P,  pubes.2 

nized  by  its  cord-like  appearance.     On  making  a  longitudinal  slit  in 
the  sheath,  the  smooth  glistening  pink  surface  of  the  round  ligament 

1  Lapthorn  Smith.      The  Medical  News.  September  29,  1896. 

2  Modified  from  Kellogg.    Proceedings  Michigan  State  Medical  Society,  1889. 


696  DISPLACEMENTS. 

appears.  From  this  time  the  operation  on  that  side  is  simple.  As 
soon  as  the  identity  of  the  ligament  is  clearly  established  by  the  fact 
that  it  can  be  "  readily  pulled  out  from  the  direction  of  the  internal 
ring — that  is,  made  to  run  " — it  is  secured  from  slipping  back  into  the 
canal  by  passing  a  ligature  loosely  around  it  and  covering  the  wound 
with  protective  gauze,  while  the  ligament  on  the  opposite  side  is  found 
and  exposed  in  the  same  manner. 

When  the  ligament  is  separated  from  its  surroundings  it  will  usu- 
ally run  freely,  and  this,  aside  from  the  eye,  is  the  best  test  of  its 
identity.  Even  the  eye  may  be  deceived,  for  in  this  region  are 
several  structures  that  closely  resemble  the  ligament.  If  the  liga- 
ment is  not  readily  found  by  the  hooks,  as  described  above,  they 
should  be  introduced  again,  and,  if  necessary,  yet  again.  Oftentimes 
it  will  be  found  outside  of  its  sheath,  crowded  down  close  to  Poupart's 
ligament  at  the  very  bottom  of  the  canal,  or  it  may  be  at  the  opposite 
side  of  the  canal.  Give  the  hook  a  broad  sweep,  so  as  to  engage 
the  entire  contents  of  the  canal.  If  necessary,  the  incision  may  be 
prolonged  to  the  internal  ring,  or  another  short  incision  may  be  made 
into  the  canal  at  the  internal  ring,  after  the  method  of  Frank  and 
Newman,  and  the  ligaments  sought  there.  A  little  patience  an(i  care 
usually  will  lead  to  success.  Failure  to  find  the  ligament  is  to  be 
attributed  not  to  its  absence,  but  to  faulty  technique. 

The  ligament,  once  found  and  isolated,  will,  as  has  been  said,  usu- 
ally run  freely.  It  should  be  drawn  out  by  gentle,  steady  traction  until 
it  begins  to  increase  rapidly  in  size  and  to  present  a  sort  of  shoulder. 
This  indicates  that  a  point  near  the  horn  of  the  uterus  has  been 
reached.  At  this  point  the  ligament  is  surrounded  by  a  fold  of  peri- 
toneum, the  canal  of  Nuck,  which  is  dragged  through  the  internal 
ring  into  the  inguinal  canal.  It  is  well  to  free  both  ligaments  before 
pulling  them  out  to  the  necessary  extent.  In  some  cases  they  are 
quite  small,  and  therefore,  if  strongly  pulled,  are  liable  to  break  and 
retreat  into  the  internal  ring  beyond  reach.  By  careful  and  repeated 
trials,  however,  they  will  usually,  as  they  are  gently  drawn  out,  become 
larger  and  appear  as  smooth,  glistening  cords. 

The  extent  to  which  the  ligaments  should  be  pulled  out  is  a  matter 
for  judgment ;  in  each  case  sufficient  slack  should  be  taken  up  to 
secure  the  corpus  uteri  in  its  normal  anterior  position.  The  rapid 
enlargement  of  the  ligament  and  the  appearance  of  the  canal  of  Nuck 
indicate  a  safe  limit. 

In  separating  the  ligament  and  drawing  it  out,  great  care  should  be 
taken  not  to  injure  nor  include  the  ilio-inguinal  nerve.  Division  of 
this  nerve  has  caused  ansesthesia  of  the  inguinal  region  repeatedly.^ 

Anchoring  the  Ligaments  in  Alexander's  Operation. 

The  ligament  having  been  drawn  out  to  the  required  extent,  as 
shown  in  Figure  391,  the  end  of  its  loop  at  C,  Figure  392,  is  transfixed 
and  tied  with  a  ligature.  The  ends  of  the  ligature  are  left  long,  and 
together  threaded  into  a  blunt  needle.      The  needle  then  is  passed 

« Edebohls.    American  Gynecological  and  Obstetrical  Journal,  December,  1896. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.    697 

Figure  391. 


Drawing  out  round  ligament  and  stripping  back  investing  peritoneum  from  the  broad 

ligament.i 

Figure  392. 


The  ligament  drawn  out  to  the  required  extent.  Ligature  passed  through  the  ligament  at 
the  loop.  Loop  being  drawn  by  means  of  a  blunt-pointed  needle  under  the  tendon  of  the  exter- 
nal oblique,  to  emerge  at  the  opposite  end  of  the  wound.  The  blunt  end  (eye  end)  of  a  needle 
would  answer  the  purpose. 

'  Suggested  by  Edebohls. 


698 


DISPLA  CEMENTS. 


under  the  tendon  of  the  external  oblique  muscle,  and  emerges  at  F, 
where  previously  there  has  been  made  into  the  inguinal  canal  a  short 
slit,  through  which  the  loop  of  round  ligament  is  now  drawn.  The 
original  slit  through  which  the  ligament  was  drawn  first  out  of  the 
inguinal  canal  is  closed  with  fine  catgut  sutures  and  the  remaining 


FiorKE  393. 


Loop  drawn  out  at  pubic  end  of  wound.    Original  opening  into  inguinal  canal  closed  with 
sutures.    Two  shorter  needles  now  take  the  place  of  the  single  long  blunt  needle. 

external  portion  of  the  loop  is  folded  down  on  the  tendon  of  the 
external  oblique  muscle,  and  stitched  there  in  the  manner  shown  by 
Figure  394. 

Figure  394. 


Loop  of  the  ligament  folded  down  on  the  tendon  of  the  external  oblique  muscle,  and  the  two 
free  ends  of  the  ligature  passed  through  at  a  and  6,  to  be  tied  for  the  closure  of  the  wound. 

The  two  ends  of  the  ligature  then  are  used  as  continuous  buried 
sutures  for  the  secure  anchoring  of  the  ligament  and  the  closure  of  the 
wound.  The  wound  closure  is  similar  to  that  laid  down  in  Chapter 
VI.  for  closure  of  the  abdominal  wound.  Chromic  catgut  is  used  for 
ligatures  and  sutures  throughout  the  operation. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.      699 

After-treatment  in  Alexander's  Operation. — The  immediate 
after-treatment  is  the  same  as  for  laparotomy.  It  is  a  wise  precau- 
tion, though  usually  unnecessary,  during  the  first  month  after  opera- 
tion— that  is,  until  strong  healing  is  secured — to  guard  against  recur- 
rence of  the  displacement  by  the  use  of  a  pessary. 

Limited  Scope  of  Alexander's  Operation. — Alexander's  opera- 
tion is  limited  to  cases  of  slight  descent  with  retroversion  or  retro- 
flexion, in  which  the  uterus  is  easily  replaceable  and  demonstrably  free 
from  complicating  adhesions,  tumors,  or  diseased  appendages.  Such 
uncomplicated  slight  displacements  usually  may  be  treated  satisfac- 
torily by  the  mechanical  support  of  pessaries  or  by  other  conservative 
measures.  The  scope,  therefore,  of  Alexander's  operation  necessarily 
is  small. 

Intra-abdominal  Shortening  of  the  Round  Ligaments.^ 

Alexander's  operation  and  other  operations  for  shortening  the  round 
ligaments,  whether  by  means  of  incision  into  each  inguinal  canal  or 
through  the  inguinal  region  on  either  side  into  the  pelvic  cavity,  have 
in  great  measure  and  for  good  reason  given  way  in  later  years  to  more 
practical  procedures  in  which  the  ligaments  are  treated  intraperito- 
neally  through  a  median  laparotomy  incision.  The  vaginal  hystero- 
pexies and  the  ordinary  operations  of  abdominal  fixation  also  show 
signs  of  becoming  obsolete.  The  suspension  operation  of  Kelly,  how- 
ever, by  which  the  upper  part  of  the  posterior  wall  of  the  corpus  uteri 
is  attached  to  the  anterior  abdominal  wall  near  the  bladder,  should  not 
be  set  aside  without  some  reservation.  At  least,  after  a  very  extensive 
experience  with  this  operation,  I  have  not  observed  in  my  own  cases 
the  injurious  mechanical  results  which  others  have  attributed  to  it. 
Possibly  these  injurious  results  have  followed  fixation,  an  operation 
always  to  be  condemned,  I'ather  than  the  suspension  advocated  by 
Kelly.  At  any  rate  the  two  operations  have  been  much  confused 
with  one  another.  Suspension  for  the  most  part  is  free  from  the  objec- 
tions which  properly  have  been  urged  against  fixation,  but  even  better 
than  suspension  is  the  newer  operation  of  shortening  the  round  liga- 
ments, because  while  being  quite  as  effective,  it  is  less  objectionable 
from  the  mechanical,  anatomical,  and  symptomatic  points  of  view. 

In  the  excellent  operation  of  Gilliam  and  the  improvements  on  it 
recently  introduced  by  Barrett  and  others  the  round  ligaments  are 
drawn  through  an  artificial  canal  into  the  laparotomy  wound  and  fast- 
ened there  either  to  one  another  or  to  the  corresponding  sides  of  the 
wound,  so  that  this  wound  when  closed  shall  contain  the  loops  of  the 
ligaments  thus  drawn  into  it. 

The  method  is  satisfactory  provided  there  is  no  subsequent  suppu- 
ration in  the  abdominal  wound,  but  it  should  be  a  fair  a  jyi'iori  conclu- 
sion that  if  the  wound  becomes  infected  the  infection  would  be  apt  to 
extend  through  the  tracks  of  the  ligaments  into  the  peritoneal  cavity, 
and,  to  say  nothing  of  unnecessary  spreading  of  infection,  might  at 
least  defeat  the  purpose  of  the  operation.  The  danger  of  such  a  source 
of  infection  is  obviated  by  the  modified  technique  about  to  be  described. 

1  American  Journal  of  the  Medical  Sciences,  June,  1906. 


700 


DISPLA  CEMENTS. 


This  technique  has  for  its  object  the  making  of  an  artificial  inguinal 
canal  on  each  side,  through  which  a  loop  of  the  round  ligament  is 
drawn  and  anchored,  not  in  the  abdominal  wound,  but  on  the  perito- 


FiGURE  395. 


The  abdomen  is  opened  in  the  median  line  just  above  the  pubes  and  the  wound  is  held 
apart  widely  by  retractors  so  as  to  expose  the  pelvic  contents.  The  middle  of  the  relaxed  round 
bgament  is  seized  with  forceps  and  tied  with  a  catgut  suture  at  a  point  just  above  A.  The  two 
free  ends  of  this  suture  are  then  threaded  on  a  curved  blunt-pointed  needle  the  size  of  a  goose 
quill  and  this  needle  is  then  thru.'st  through  peritoneum  at  the  internal  abdominal  ring,  traction 
on  the  ligament  having  been  made  in  order  to  locate  the  ring  at  point  A.  Tlie  needle  is  then 
passed  on  through  the  rectus  muscle  and  fascia  and  then  turned  and  forced  through  fascia, 
muscle,  and  peritoneum  to  its  xj^int  of  exit  close  to  the  bladder  reflexion,  about  one  one-half 
inch  from  the  peritoneal  margin  of  the  abdominal  incision  at  point  B.  The  blunt  needle  is 
then  removed  and  the  loop  of  ligament  is  drawn  through  the  artificial  inguinal  canal  by  means 
of  the  suture  from  A  to  B,  as  shown  on  the  right  side  of  Figure  396.  In  place  of  this  blunt 
needle  one  may  use  a  ligature-carrying  forceps.  The  artificial  canal  lies  between  points  A  and 
B.  In  order  to  avoid  wounding  the  deep  epigastric  and  other  vessels  the  needle  should  be 
blunt-7Xjinted  and  the  plunge  of  it  should  not  be  too  deep  into  the  region  of  the  internal  ring. 
The  needle  should  be  about  two  and  one-half  inches  long  and  flattened  both  on  its  convex  and 
concave  sides  in  order  that  it  may  be  held  firmlv  in  the  needle  forceps,  and  with  a  point  espe- 
cially blunt  to  make  it  pass  by  blood-vessels  without  wounding  them,  but  not  so  blunt  as  to 
prevent  introduction. 


neal  surface  at  a  point  a  little  distant  from  and   independent  of  the 
wound.  ^   Figures  395  and  396  will  .serve  to  illustrate  the  method. 

^  It  will  be  observed  that  the  uterus  which  appears  retroverted  in 
Figure  395  takes  its  anteverted  position  in  Figure  396. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.      701 

lu  some  cases  the  ligament  on  one  or  both  sides  will  be  found  to 
be  absent  or  so  attenuated  as  to  give  little  hope,  even  though  shortened, 
of  being  adequate  to  sustain  a  heavy  uterus.  It  may  then  be  well  to 
substitute  for  the  above  operation  the  procedure  shown  in  Figure  397, 
which  is  to  crumple  the  rudimentary  ligament  upon  itself  by  means 
of  a  purse-string  catgut  suture  running  from  the  internal  inguinal 
ring  to  the  uterus. 

Figure  396. 


Continuation  of  Figure  395.  The  ligament  having  been  drawn  through  the  artificial  inguinal 
canal  is  then  stitched  with  catgut  at  its  point  of  entrance  at  .i,and  the  loop  in  a  similar  manner 
is  stitched  down  on  the  peritoneum  at  the  point  of  exit  B.  The  left  side  of  the  figure  shows 
the  ligament  thus  stitched  at  the  point  of  entrance  and  being  stitched  at  its  point  of  exit.  This 
having  been  done  on  both  sides  completes  the  shortening.  The  abdominal  wound  is  then 
closed. 

Shortening  the  Uterosacral  Ligaments. 

Any  operation  for  shortening  or  strengthening  the  round  ligaments 
may  fail  to  give  satisfactory  results  if  the  uterosacral  ligaments  are 
so  relaxed  that  they  cannot  perform  their  function  of  holding  the 
cervix  uteri  in  its  normal  location  back  in  the  hollow  of  the  sacrum. 


702 


DISPLA  CEMENTS. 


It  may  be  necessary,  therefore,  that  these  ligaments  be  shortened  also. 
Figures  398  and  399  illustrate  the  operation  usually  performed  for 
this  purpose,  and  show  the  change  which  the  shortening  makes  in  the 
location  of  the  cervix  uteri.  Reference  here  is  made  to  shortening  the 
ligaments  only  through  an  abdominal  incision.  A  very  exhaustive 
paper  on  the  shortening,  both  vaginal  and  abdominal,  of  the  utero- 
sacral  ligaments,  with  bibliography,  by  J.  AVesley  Bovee,  may  be  found 
in  the  Transactions  of  the  American  Gynecological  Societi/,  1902. 

Figure  397. 


Traction  being  made  on  the  ligament  in  order  to  locate  its  point  of  entrance  at  the  internal 
inguinal  ring.  An  ordinary  needle  is  introduced  at  this  point  and  the  round  ligament  and  the 
adjacent  part  of  the  broad  ligament  are  causht  up  from  point  to  point  until  the'suture  finallv 
is  brought  out  in  uterine  tissue  near  the  uterine  end  of  the  round  ligament.  The  tving  of  the 
suture,  which  should  not  be  drawn  too  tightlv,  shortens  and  strengthens  the  ligament  bv 
crumpling  it  on  itself.  If  the  ligament  is  absent  or  highlv  attenuated,  the  structures  of  the 
broad  ligament  between  the  horn  of  the  uterus  and  the  internal  ring  mav  be  brought  together 
by  a  similar  suture  with  similar  result.  Before  tving  the  sutures  the  surfaces  to  be  united 
should  be  scarified  in  order  to  secure  strong  union. 

It  is  perhaps  needless  to  add  that  the  success  of  the  operations 
above  described  may  demand  thorough  repair  of  a  lacerated  perineum, 
or,  more  comprehensively  speaking,  may  require  adequate  operative 
work  upon  a  relaxed  vaginal  outlet  and  sometimes  even  upon  a  relaxed 
vaffina. 


Abdominal  Hysterorrhaphy. 

Suspen-sion  of  the  uterus  by  abdominal  hysterorrhaphy  is  known 
as  the  Howard  Kelly  operation.  The  object  of  the  operation  is  to 
replace  the  uterus  and  secure  it  in  its  normal  position  by  means  of 
sutures  so  placed  as  to  unite  it  with  the  anterior  abdominal  wall. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.      703 

Figure  398. 


The  uterosacral  ligaments  are  exposed  and  a  purse-string  suture  is  introduced  for  the  pur- 
pose of  shortening  them  and  partially  tied,  but  not  drawn  taut.  Before  tightening  the  sutures 
the  surfaces  to  be  united  should  be  scarified  in  order  to  ensure  firm  union  of  the  peritoneal 
surfaces.  In  order  to  avoid  wounding  important  nerves  and  vessels  the  sutures  should  be 
passed  superficially. 

Figure  399. 


Continuation  of  Figure  39S.  The  cnttrut  sutures  shown  in  Figure  SuT  are  ivw  drawn  taut 
and  tied.  These  sutures  having  been  tied  usually  should  be  fortified  by  an  additional  suture 
through  the  crumpled  ligament  on  each  side.  Tl'tis  figure  shows  the  cervix  uteri  draivn  well  back 
into  its  noi-vial  location  so  near  the  hollow  of  the  sacrum  that  the  corpus  cannot  have  room  to  fall  back 
into  its  forTner  retroverted  position. 

Nomenclature  of    Hysterorrhaphy. 

Hysterorrhaphy  has  been  known  under  various  names,  some  of  them 
more  or  less  descriptive  of  special  methods  of  operation.  They  are : 
ventral  fixation,  abdominal  fixation,  suspensio  uteri,  and  hysteropexy. 


704 


DISPLA  CEMENTS. 


Impediments  to  Replacement. 

The  incision  having  been  made,  the  left  index-finger  is  introduced 
into  the  pelvis  and  a  thorough  study  made  of  all  the  intrapelvic 
organs.  Before  the  uterus  can  be  replaced  adhesions  may  have  to  be 
broken  up,  tumors  of  the  uterus  or  its  appendages  may  have  to  be 
removed,  and  conservative  or  radical  operations  upon  the  Fallopian 
tubes  or  ovaries  may  be  necessary. 

Posterior  displacements  of  the  uterus  are  associated  often  with  sal- 
pingitis, ovaritis,  and  adhesions,  which  would  render  mechanical  treat- 
ment by  a  pessary  or  shortening  of  the  round  ligaments  useless  or 


Figure  400. 


Suture  wrongly  placed  in  the  anterior  wall  of  the  corpus  uteri.  The  arrow  points  in  the 
direction  of  the  forces  that  fall  on  the  anterior  uterine  wall  and  tend  to  force  the  organ  back, 
and  thereby  to  reproduce  the  displacement. 

dangerous.  The  occasional  failure  to  recognize  these  extra-uterine 
complications  accounts  for  some  disastrous  results  which  have  followed 
mechanical  treatment  and  Alexander's  operation.  The  great  advantage 
of  hysterorrhaphy  is  that  the  peritoneal  cavity  is  open  to  direct  exam- 
ination and  complete  diagnosis.  The  surgeon,  therefore,  as  he  proceeds, 
may  avoid  unsuspected  sources  of  failure  or  danger.  The  very  con- 
traindications for  Alexander's  operation  become  the  indications  for 
hysterorrhaphy.  The  impediments  to  replacement  and  fixation  having 
been  overcome  or  removed,  the  operation  proper — that  is,  fixation — 
may  be  undertaken. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.      705 

The  Conditions  of  Successful  Hysterorrhaphy. 

The  sutures  should  be  placed  slightly  posterior  to  a  line  connecting 
the  two  horns  of  the  uterus — that  is,  in  the  posterior  wall.  The  earlier 
operators  stitched  the  anterior  wall  of  the  corpus  to  the  abdominal 
wall.  By  this  arrangement  the  uterus  is  so  placed  that  contraction  of 
the  abdominal  muscles  and  the  intra-abdominal  forces  must  be  exerted 
against  the  front  of  the  uterus,  and  must  therefore,  by  forcing  the 
uterus  back,  ultimately  stretch  or  break  the  adhesions  and  reproduce 
the  displacement.  If,  on  the  contrary,  the  posterior  wall  of  the  corpus 
be  stitched  properly  to  the  anterior  abdominal  ^v^ll,  all  the  forces  from 
above  are  exerted  on  the  posterior  wall  of  the  corpus,  and  thereby  tend 
to  perpetuate  the  normal  anterior  position.^ 

Another  condition  of  success  is  to  limit  the  adhesions  between  the 
uterus  and  the  abdominal  wall.     When  the  adhesion  is  to  the  posterior 


Figure  401. 


Posterior  wall  of  the  corpus  properly  stitched  to  the  anterior  abdominal  wall.  The  arro\V 
shows  the  direction  of  forces  from  above  so  exerted  as  to  fall  on  the  posterior  uterine  wall,  and 
thereby  perpetuate  the  normal  anterior  position. 

wall  of  the  corpus  uteri,  it  is  surprising  how  slight  it  may  be  and  yet 
make  a  permanently  good  result.  The  object  of  the  operation  is  not 
to  fix  the  uterus  immovably  to  the  abdominal  wall  by  broad  areas  of 
adhesion ;  such  a  result  is  produced  sometimes  by  numerous  deep 
sutures  and  extensive  scarifications  of  the  anterior  or  posterior  face 
of  the  uterus.  The  broad  unyielding  adhesions  thus  obtained  must 
interfere  with  the  normal  movements  of  the  uterus,  and  thereby  give 

»  The  necessity  for  uniting  the  posterior  wall  of  the  corpus  uteri,  instead  of  the  anterior 
wall,  to  the  parietal  peritoneum  of  the  abdominal  wall,  was  pointed  out  first  by  Howard 
Kelly. 


706  DISPLACEMENTS. 

rise  to  a  condition  more  distressing  than  the  displacement.  Figure  402 
shows  the  abdomen  open  and  three  hysterorrhaphy  sutures  passed,  but 
not  tied. 

Occasional  cases  of  dystocia,  some  of  them  demanding  craniotomy 
or  even  Csesarean  section,  bear  witness  to  the  danger  of  excessive 
uterine  adhesions  to  the  abdominal  wall.  After  the  operation  the 
adhesions,  if  properly  made,  do  not  remain  as  such,  but  stretch  out 
so  far  as  to  form  a  short,  ribbon-like  band  between  the  uterus  and 
the  abdominal  wall.  This  band  contains  connective  tissue  and 
possibly  some  fibres  from  the  recti  and  uterine  muscles,  and  is 
covered  by  peritoneum  ;  it  is  therefore  a  new  suspensory  ligament 
designed  to  supplement  the  inadequate  uterine  ligaments.  This  liga- 
ment has  been  demonstrated  by  dissection  years  after  the  operation.^ 
It  is  usually,  when  fully  stretched,  about  two  inches  long.  This  elon- 
gation of  the  adherent  structures  into  a  new  uterine  ligament  cannot 
occur  if  the  adhesions  are  too  extensive  and  too  strong. 

Technique  of  Hysterorrhaphy. 

The  incision,  general  conduct  of  the  operation,  closure  of  the  wound, 
and  after-treatment  are  the  same  as  for  anv  other  abdominal  section. 
See  Chapters  VI.,  VII.,  and  VIII. 

The  introduction  of  the  hysterorrhaphy  sutures  varies  in  minor 
details  according  to  the  individual  preference  of  the  operator.  The 
writer  uses  two  formaldehyde  catgut  sutures,  one  on  each  side  of  the 
posterior  wall  of  the  corpus  uteri. 

An  abdominal  incision  from  one  to  two  inches  long  is  made  in  the 
median  line  just  above  the  pubes.  The  margins  of  the  peritoneum 
are  drawn  through  the  wound  over  the  cutaneous  margins,  and  are 
held  outside  by  hsemostatic  forceps,  as  shown  in  Figure  393.  The 
corpus  uteri  is  lifted  forward  by  the  left  index-finger  and  middle 
finger  introduced  through  the  wound,  and  is  held  in  place  by  light 
vulsellum  forceps  in.  the  hands  of  an  assistant. 

The  teeth  of  the  forceps  grasp  the  posterior  surface  of  the  corpus  in 
the  median  line  about  one-half  inch  back  of  the  summit  of  the  fundus. 
The  operator,  standing  on  the  patient's  right,  passes  a  short  needle, 
slightly  curved  at  the  point  and  threaded  with  fine  formaldehyde  cat- 
gut, into  the  everted  peritoneum  on  the  left  side.  The  needle  enters 
just  above  the  lower  angle  of  the  wound,  about  three-quarters  of  an 
inch  from  the  peritoneal  margin ;  it  dips  down  about  one-quarter  of  an 
inch  so  as  to  include  some  fibres  of  the  rectus  muscle,  and  emerges 
about  one-half  inch  from  the  point  of  entrance.  The  needle  then  is 
reintroduced  into  the  posterior  wall  of  the  corpus  to  one  side  of  the 
median  line  near  the  horn  of  the  uterus.  Care  should  be  taken  not  to 
puncture  the  Fallopian  tube.  The  uterine  part  of  the  suture  should 
include  sufficient  peritoneal  and  subperitoneal  tissue  to  give  it  a  strong 
hold  on  the  uterus.  The  free  ends  of  this  suture  now  are  fastened 
together  by  snap-forceps  and  laid  to  one  side.  Another  similar  suture 
is  passed  on  the  opposite  side.     It  is  convenient  in  passing  this  to  do 

1  Penrose.    Diseases  of  Women. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.      707 

SO  in  the  reverse  order — that  is,  to  pick  up  the  uterus  first  and  the 
abdominal  peritoneum  second.  A  third  suture  now  is  introduced 
through  the  parietal  peritoneum  near  the  first  suture,  then  through 
the  corpus  uteri  between  the  two  first  sutures  and  through  the  parietal 
peritoneum  near  the  second.     The  three  sutures  being  thus  passed,  a 


Figure  402. 


Peritoneal  margins  of  the  wound  everted  to  the  outside  by  snap-forceps.  Corpus  uteri  held 
steady  by  a  vulsellum  forceps.  Sutures  on  both  sides  and  in  the  centre  of  the  corpus  passed 
but  not  tied. 

final  examination  of  the  pelvic  contents  is  made  ;  and  if  all  is  well,  the 
sutures  are  tied.  This  secures  the  upper  posterior  wall  of  the  corpus 
uteri  to  the  anterior  abdominal  wall.  The  external  wound  then  is 
closed  by  continuous  catgut  suture,  as  directed  in  Chapter  VI.  There 
is  no  occasion  for  scarifying  the  peritoneal  surfaces ;  indeed,  this  should 
not  be  done.  Adequate  adhesion  will  always  form  from  the  presence 
of  the  sutures.     The  pessary  is  not  needed  during  convalescence. 


708  DISPLACEMENTS. 

Immediately  after  the  operation,  while  the  uterus  is  fixed  immov- 
ably, there  may  be  some  bladder  irritation  ;  but  in  a  few  weeks,  when 
the  adherent  structures  have  stretched  and  formed  a  new  suspensory 
ligament  and  the  uterus  has  assumed  its  normal  state  of  mobile  equi- 
librium, the  vesical  irritation  disappears.  This  operation  properly  per- 
formed gives  more  security  against  recurrence  of  displacement  than  any 
of  the  ligament-shortening  operations. 

Vaginal  Hysterorrhaphy.^ 

The  purpose  of  this  operation  is  to  anchor  the  uterus  in  its  normal 
anterior  position  by  stitching  the  anterior  wall  of  the  uterus  to  the 
anterior  wall  of  the  vagina. 

Technique  of  Vaginal  Hysterorrhaphy. 

Vaginal  section  is  made  as  directed  in  Chapter  XXIII.  The 
patient  is  on  her  back,  with  the  cervix  uteri  and  anterior  vaginal 
wall  exposed  by  means  of  Simon's  speculum  and  other  retractors. 
The  uterus  is  drawn  downward  and  backward  by  means  of  vulsellum 
or  bullet  forceps.  The  anterior  vaginal  wall  is  put  upon  the  stretch 
by  means  of  a  small  vulsellum  forceps  fastened  to  the  vagina  in  the 
median  line  midway  between  the  meatus  urinarius  and  the  cervix 
uteri.  A  median  longitudinal  incision  then  is  made  in  the  anterior 
vaginal  wall  extending  from  the  cervix  uteri  one  inch  or  more  toward 
the  meatus.  This  incision,  which  divides  the  vaginal  wall,  but  does 
not  invade  the  bladder-wall,  is  separated  by  retractors,  the  cervix  is 
drawn  more  strongly  forward,  and  the  loose  cellular  tissue  adjacent  to 
the  anterior  wall  of  the  cervix  is  stripped  back  by  means  of  the  finger 
or  blunt  instrument  until  the  uterovesical  reflection  of  the  peritoneum 
is  reached.     See  Figures  170  and  171. 

A  sound  in  the  bladder  will  distinguish  the  peritoneum  from  the 
bladder- wall.  The  peritoneum,  then  exposed,  is  seized  with  the  tenac- 
ulum or  snap-forceps,  and  divided  with  blunt  scissors.  The  peritoneal 
opening  next  is  enlarged  by  introducing  the  two  index-fingers  and 
tearing  and  stretching  it  laterally,  or  by  careful  cutting  with  the 
scissors.  The  large  opening  thus  made  between  the  uterus  and  the 
bladder  will  permit  the  bladder  to  be  pushed  up  out  of  the  way  and 
the  corpus  uteri  to  be  drawn  through  into  the  vagina  and  down  to 
the  vulva.  If  there  are  restraining  posterior  or  lateral  adhesions, 
they  may  be  broken  up  by  the  finger  introduced  through  this  opening 
or  through  a  similar  one  made  for  the  purpose  posterior  to  the  uterus. 
See  Posterior  Vaginal  Section.  The  uterus,  being  freed,  is  drawn 
into  the  vagina  by  successively  grasping  its  anterior  wall  with  two 
pairs  of  vulsellum  forceps,  one  in  each  hand,  using  first  one  and  then 
the  other,  until  the  fundus  finally  appears  and  with  it  the  appendages. 
Any  necessary  operation  on  the  uterus  or  its  appendages  may  now  be 
performed ;  there  may  be  a  small  myoma  to  be  enucleated,  or  some 
conservative  or   radical  operation  to  be   performed  on  the    uterine 

1  This  operation  has  passed  through  numerous  modifications,  is  still  sub  judice,  and  is  not 
strongly  recommended.  Among  the  names  chiefly  associated  with  the  evolution  are  those  of 
Schucliing,  Sanger,  Mackenrodt,  Duhrssen,  Byford,  and  Vineberg. 


TREATMENT  OF  RETROVERSION  AND  RETROFLEXION.      709 

appendages.  The  uterus  is  now  ready  to  be  fastened  to  the  anterior 
vaginal  wall,  as  follows  : 

A  needle,  such  as  would  be  used  for  closing  the  lacerated  cervix,  is 
threaded  with  silkworm  gut,  and  by  means  of  the  needle-forceps  is 
passed  through  the  flap  of  the  vaginal  incision  near  the  urethra,  on  the 
patient's  left,  then  continued  transversely  through  the  anterior  wall 
of  the  uterus  near  the  fundus,  and  brought  out  through  the  vaginal 
flap  on  the  opposite  side.  Another  similar  suture  is  passed  immedi- 
ately below  this.  These  uterine  sutures  are  not  tied  until  after  closure 
of  the  vaginal  incision.  The  vaginal  incision  is  closed  with  a  con- 
tinuous buried  catgut  suture  in  a  manner  similar  to  that  described  in 
Chapter  VI.,  for  closure  of  an  abdominal  wound.  The  vagina  is 
packed  lightly  with  aseptic  gauze  and  an  aseptic  dressing  is  placed 
over  the  vulva.  The  dressings  should  be  changed  often  enough  to 
keep  them  clean.  After  three  days  the  vaginal  gauze  may  be  left  out, 
and  in  its  place  may  be  given  a  daily  hot  aseptic  vaginal  douche. 
The  silkworm  gut  sutures  are  removed  in  four  weeks.  Chromic  cat- 
gut, if  used  in  place  of  silkworm,  need  not  be  removed.^ 

Unless  the  adhesions  between  the  uterus  and  the  vagina  be  very 
broad  and  very  strong,  they  are  liable  in  a  few  weeks  to  give  way, 
with  complete  return  of  the  displacement.  If,  on  the  other  hand,  the 
adhesions  are  sufficiently  strong  and  broad  to  make  a  permanent  ana- 
tomical cure,  and  pregnancy  follows,  the  danger  from  dystocia  is  very 
great.  Numerous  cases  have  been  reported,  some  of  them  fatal,  in 
which  Csesarean  section  or  other  grave  obstetric  operations  became 
necessary  for  delivery.  The  operation  therefore,  as  described  above, 
is  not  approved  for  cases  in  which  pregnancy  may  occur. 

Complicating  Versions  and  Flexions. 

The  lateral  malpositions  which  often  complicate  retroversion  and 
retroflexion  are  usually  the  result  of  inflammation  in  a  broad  ligament 
or  in  the  uterus,  or  in  both.  They  are  caused  sometimes  by  a  tumor 
of  the  uterus  or  its  appendages.  The  treatment  is  that  of  the  causa- 
tive inflammation  or  tumor,  and  follows  the  general  principles  that 
have  been  laid  down  for  the  treatment  of  these  conditions.  Pessaries 
are  of  little  or  no  use. 

In  Congenital  Retroversion  and  Retroflexion  it  is  doubtful  whether 
any  treatment,  surgical  or  non-surgical,  is  of  the  least  value.  This 
form  of  displacement  is  associated  usually  with  faulty  development, 
both  general  and  local.  The  concurrent  symptoms  also  are  due  rather 
to  general  than  to  local  causes. 

1  The  method  described  above  is  similar  to  that  advocated  and  successfully  practised  by 
Vineburg.    New  York  Medical  Journal,  October,  1894. 

43 


CHAPTER  XLVIII. 

ANTEVERSION  AND  ANTEFLEXION  OF  THE  UTERUS : 
TORSION  OF  THE  UTERUS. 

PATHOLOGICAL   ANTEVERSION   OF   THE   UTERUS. 

A  CERTAix  degree  and  condition  of  anteflexion  is  normal.  See 
Normal  Position  and  Normal  Movements  of  the  Uterus,  in  Chapter 
XLIV.  The  evils  of  pathological  anteflexion  are  more  a  matter  of 
the  associated  lesions  than  of  the  displacement  per  se. 

Sometimes  the  physiological  angle  of  flexure  becomes  obliterated  in 
consequence  of  chronic  metritis,  and  results  in  permanent  straighten- 
ing of  the  uterus.  The  cervix  becomes  elevated  and  fixed  above,  or 
the  corpus  depressed  and  fixed  below  the  normal  level.  This  consti- 
tutes pathological  anteversion.      Figure  403. 

Ante  version  is  associated  often  with  pathological  anteflexion.  The 
mobility  at  the  angle  of  flexure  then  is  increased,  diminished,  or 
absent ;  the  flexure  is  then  the  significant  factor,  and  will  be  con- 
sidered under  Pathological  Anteflexion. 

Etiolog-y  and  Symptoms  of  Anteversion. 

The  causes  of  pathological  anteflexion  may  be  summarized  as 
follows : 

1.  Adhesions  in  front  of  the  uterus,  drawing  the  corpus  forward. 

2.  Tumors  behind  the  uterus,  pushing  the  fundus  forward. 

3.  Metritis,  increasing  the  weight  of  the  uterus. 

4.  Small  fibroids  in  the  anterior  wall  of  the  uterus. 

5.  Congenital. 

The  exaggerated  anteversion  of  early  pregnancy  is  physiological ; 
the  exaggerated  anteversion  of  the  uterus  in  chronic  metritis  is  patho- 
logical. Elevation  of  the  cervix  and  depression  of  the  corpus  uteri 
may  be  induced  by  peritoneal  adhesions.  Increased  weight  from  a 
mural  myoma  also  may  depress  the  corpus. 

The  symptoms  are  due  to  the  pelvic  inflammations  and  other  com- 
plications already  mentioned.  The  increased  weight  of  the  uterus, 
which  usually  is  hypertrophied  from  metritis,  generally  causes  a  drag- 
ging sensation,  especially  if  the  organ  be  prolapsed.  The  enlarged 
corpus  occupying  the  territory  of  the  bladder  often  induces  persistent 
vesical  irritation,  or  even  cystitis.  Menorrhagia,  when  present,  is  the 
result  of  the  metritis  or  of  a  myoma,  rather  than  of  the  displacement 
itself.  The  symptoms  usually  attriljuted  to  anteversion  usually  are 
due  rather  to  the  complications  than  to  the  malposition. 
710 


ANTEVERSION  AND  ANTEFLEXION  OF  THE   UTERUS.       711 

Diagnosis  and  Prognosis  of  Anteversion. 

The  displacement  is  recognized  by  digital  touch,  which  discloses 
the  anterior  wall  of  the  enlarged  uterus  parallel  to  the  anterior  wall 
of  the  vagina,  with  the  fundus  close  to  the  symphysis  and  the  cervix 
elevated.  Conjoined  examination  will  show  the  size,  shape,  hardness, 
and  degree  of  fixation.  Exaggerated  anteversion  of  the  healthy 
uterus  is  not  necessarily  pathological  in  its  results.  This  is  illus- 
trated by  the  anteversion  of  early  pregnancy.  The  prognosis  is 
good  if  the  complications  can  be  removed. 

Figure  403. 


Pathological  anteversion.    Mobility  at  angle  of  flexure  lost. 


Treatment  of  Anteversion. 

If  exaggerated  anteversion  is  often  the  position  taken  by  the  uterus 
in  chronic  metritis,  it  follows  that  the  treatment  often  will  be  that  of 
chronic  metritis.  For  the  treatment  of  metritis,  perimetritis,  myoma, 
menorrhagia,  and  other  complications  and  lesions  associated  with  the 
displacement,  the  reader  is  referred  to  those  subjects.  Irritable 
bladder,  which  is  often  a  mechanical  result  of  the  displacement  and 
enlargement,  may  be  relieved  sometimes  by  means  of  an  Albert 
Smith  or  Hodge  pessary,  which  lifts  the  organ  to  a  higher  level 
away  from  the  bladder.  In  thus  elevating  the  uterus  the  anteversion 
may  be  increased  rather  than  diminished.  This  proves  that  the  symp- 
toms were  dependent  not  upon  the  anteposition,  but  rather  upon  de- 


712  DISPLACEMENTS. 

scent  and  antelocation.  Should  the  parts  be  too  sensitive  to  tolerate 
the  hard-rubber  pessary  or  a  flexible  rubber  ring,  the  daily  application 
of  medicated  pledgets  of  lambs'  wool  may  give  support  to  the  uterus 
and  decrease  tenderness  until  the  more  permanent  instrument  can  be 
worn.  The  numerous  anteversion  pessaries  designed  to  elevate  the 
corpus  by  direct  pressure  on  the  anterior  wall  of  the  uterus  generally 
irritate  the  organ  and  thereby  aggravate  the  inflammatory  complica- 
tions.    They,  therefore,  are  to  be  condemned. 

Figure  404. 


Congenital  anteflexion ;  both  cervix  and  corpus  uteri  bent  forward. 

PATHOLOGICAL  ANTEFLEXION  OF  THE  UTERUS. 

A  comprehensive  study  of  pathological  anteflexion  would  have  to 
take  into  account  the  abnormal  conditions  usually  associated  with  it ; 
these  may  have  the  relation  of  cause  or  effect,  or  be  a  concurrent 
result  of  some  common  cause. 

A  distinction  between  normal  and  pathological  anteflexion  would 
show  that  an  essential  factor  in  the  former  is  mobility  at  the  angle  of 
flexure  which  permits  the  degree  of  flexure  to  vary  within  certain 
defined  limits.  The  limit  of  normal  anteflexion  is  approximately  90 
degrees.  The  physiological  variation  is  somewhat  commensurate  with 
the  varying  quantity  of  fluid  in  the  bladder. 

The  body  of  the  uterus  rests  upon  the  bladder,  and  must  rise 
as  the  bladder  becomes  distended.     Conversely,  if  the  urine  be  drawn 


ANTEVERSION  AND  ANTEFLEXION  OF  THE  UTERUS.       713 

through  a  catheter,  even  while  the  woman  is  lying  on  the  back,  the 
corpus,  notwithstanding  the  opposing  influence  of  its  own  weight, 
immediately  follows  the  receding  wall  of  the  bladder  and  returns, 
through  an  angle  of  45  degrees  or  possibly  even  90  degrees,  to  its 
accustomed  position. 

The  normal  forward  bending  of  the  corpus  upon  the  cervix  uteri 
when  the  bladder  is  empty  makes  an  angle  of  which  the  approximate 
physiological  limits  are  between  45  degrees  and  90  degrees  ;  the  flex- 
ure, therefore,  would  generally  be  pathological  if  less  than  45  degrees 
or  more  than  90  degrees.  Furthermore,  if  the  flexure,  whether  it 
be  normal  or  abnormal  in  extent,  does  not  disappear  upon  filling 
the  bladder,  but  remains  constant  under  all  conditions,  the  rigidity 
makes  the  flexure  pathological. 

Anteflexion  is,  therefore,  pathological  if  the  mobility  at  the  angle 
of  flexure  is  increased  or  diminished,  or  absent. 

Etiology  and  Classification  of  Anteflexion. 

Anteflexion  may  be  either  congenital  or  acquired. 

Congenital  and  Developmental  Anteflexion. — The  uterus  in 
this  form  of  anteflexion  is  bent  upon  itself  almost  double,  the  body 
and  the  cervix  both  pointing  in  the  direction  of  the  pelvic  outlet.  The 
cervix  is  somewhat  elongated  and  situated  in  the  long  axis  of  the 
vagina ;  see  Figure  404.  The  cause  may  be  defective  foetal  develop- 
ment, or  failure  of  the  immature  child  uterus  to  develop  at  puberty,  a 
failure  which  usually  pertains  alike  to  the  uterus,  Fallopian  tubes, 
ovaries,  and  vagina.     A  more  proper  name  is  infantile  uterus. 

Acquired  Anteflexion  may  be  simply  an  exaggeration  of  the 
normal  flexure,  due  either  to  increased  weight  of  the  corpus  from  the 
presence  of  a  myoma  near  the  fundus,  or  to  unequal  growth  of  the 
uterine  walls,  or  to  unequal  involution,  or  to  an  abnormally  soft, 
mobile  condition  of  the  uterine  walls.  A  not  infrequent  cause  of 
anteflexion  is  thickening  of  the  posterior  wall  of  the  uterus  from  the 
products  of  inflammation,  and  a  corresponding  atrophy  of  the  ante- 
rior wall  from  prolonged  pressure  at  the  angle  of  flexure.  This  con- 
dition is  apt  to  be  associated  with  post-uterine  inflammation  involving 
the  uterosacral  ligaments,  a  frequent  and  discouraging  complication. 
Sometimes  the  inflamed  ligaments  contract  and  drag  the  anteflexed 
uterus  upward  and  backward,  where  it  may  be  fixed  permanently  in 
its  post-uterine  location  by  peritoneal  adhesions. 

Pathology  of  Anteflexion. 

Peri-uterine  inflammations  having  the  relation  of  either  cause  or 
eifect  to  the  flexure,  often  bind  the  pelvic  organs  together  in  a  mass 
of  exudate,  with  resulting  failure  of  nutrition,  nerve  irritation,  and 
constant  pain,  which  sometimes  render  the  patient's  life  miserable 
and  useless.  Constriction  or  collapse  of  the  uterine  canal  at  the  point 
of  flexure  may,  by  confining  the  secretions  above,  produce  inflamma- 
tion in  the  body  of  the  uterus.  Fallopian  tubes,  and  ovaries.     This  is 


714 


DISPLA  CEMENTS. 


analogous  to  the  cystitis,  urethritis,  pyelitis,  and  nephritis  which  fol- 
low stricture  of  the  male  urethra.  As  the  fecal  matter  passes  the 
cervix  during  defecation,  force  is  applied  to  the  posterior  cervical  wall 
in  the  direction  of  the  lower  arrow.  Figure  405.  At  the  same  time 
fixation  of  the  abdominal  muscles  due  to  straining,  whether  in  urina- 
tion or  defecation,  results  in  the  application  of  force  upon  the  corpus 
uteri  in  the  direction  of  the  upper  arrow.  Thus  the  flexure  is  in- 
creased and  perpetuated  with  defecation  and  urination. 

Symptoms,  Course,  and  Complications  of  Anteflexion. 

The  numerous  symptoms  due  to  the  inflammatory  and  other  com- 
plications should  not  be  confounded  with  those  that  directly  depend 
upon  the  displacement.     The  symptoms  of  anteflexon  usually  may  be 

Figure  405. 


^^-^-^^ 


The  arrows  show  the  influence  on  the  displacement  of  the^  forces  produced  by  straining 

at  stool. 

referred,  first,  to  the  bladder  and  urethra  :  and,  second,  to  the  uterus 
itself. 

The  Vesical  and  Urethral  Symptoms  are  produced  either  by 
rigidity  of  the  uterine  tissue  at  the  angle  of  flexure,  which  prevents 
the  corpus  uteri  from  rising  out  of  the  way  of  the  filling  bladder ;  or 
by  inflammatory  shortening  of  the  uterosacral  ligaments,  which,  by 
drawing  the  uterus  upward  and  backward,  puts  the  vesicovaginal  wall 
on  the  stretch ;  this  causes  traction  upon  the  neck  of  the  bladder  and 
consequent  bladder  and  urethral  irritation,  and  may  be  the  starting- 
point  of  cystitis  and  urethritis. 


ANTEVERSION  AND  ANTEFLEXION  OF  THE   UTERUS.       715 

Vesical  irritation  caused  by  postuterine  inflammatiou  and  conse- 
quent contraction  of  the  uterosacral  ligaments  often  is  attributed 
wrongly  to  the  mechanical  pressure  of  the  anteflexed  corpus  uteri  upon 
the  bladder ;  this  is  manifestly  impossible,  for  the  contracted  utero- 
sacral supports  hold  the  entire  uterus  far  away  from  the  bladder. 

Uterine  Symptoms. — When  the  flexure  has  gone  beyond  the 
normal  limit  and  become  pathological,  two  principal  results  may  occur, 
especially  if  there  be  immobility  at  the  angle  of  flexure  : 

1.  Collapse  of  the  blood-vessels  at  the  angle  of  flexure,  with  conse- 
quent obstruction  of  the  circulation,  passive  congestion,  and  hyper- 
secretion of  a  vitiated  mucus. 

FlGTJKE  406. 


Acquired  anteflexion  with  postuterine  fixation.     Want  of  mobility  at  angle  of  flexure. 

2.  Collapse  and  obstruction  of  the  uterine  canal  at  the  angle  of 
flexure,  with  consequent  retention  of  the  uterine  secretions.  The 
secretions  may  decompose  and  become  a  potent  source  of  irritation  ;  the 
uterine  mucosa  could  then  neither  perform  its  normal  part  in  men- 
struation nor  furnish  a  safe  resting-place  for  the  impregnated  ovum. 
The  possible  symptom-group  dependent  upon  these  two  forms  of 
obstruction  includes  endometritis,  dysmenorrhcea,  and  sterility. 

Endometritis  may  be  caused  and  perpetuated  by  the  endometrial 
and  vascular  obstruction.  The  causation  of  rhinitis  from  obstruction 
in  the  nasal  passages  and  of  cystitis  from  stricture  of  the  urethra  is 
analogous. 


716  DISPLACEMENTS. 

Dysmenorrhoea  may  depend  upon  collapse  and  constriction  of  the 
uterine  canal  at  the  angle  of  flexure.  This  causes  the  blood  to  accu- 
mulate and  to  coagulate  in  the  body  of  the  uterus,  from  which  it  is 
expelled  at  intervals  by  uterine  contractions  simulating  labor  pains. 
Pain,  when  due  to  this  cause,  is  therefore  always  specially  severe  just 
before  the  passage  of  a  clot.  Dysmenorrhoea  may  also  be  caused  by 
similar  collapse  and  consequent  obstruction  in  the  veins  at  the  angle 
of  flexure  ;  this  causes  intense  venous  congestion  of  the  entire  body 
of  the  uterus ;  pain  then  is  due  to  pressure  of  the  swollen  vessels 
upon  the  nerve-filaments  and  to  a  consequent  irritable  condition  of 
the  muscular  tissue  of  the  uterus.  Sometimes  the  uterine  canal 
becomes  temporarily  straightened  with  the  establishment  of  the  flow  ; 
this  removes  the  cause  of  the  vascular  obstruction,  and  the  pain  from 
congestion  is  relieved.  It  is  clear  that  the  pain  would  be  intensified 
in  a  uterus  hypersensitive  from  metritis,  and  especially  from  neuritis. 

Sterility  is  consequent  not  so  much  upon  failure  of  impregnation, 
as  upon  the  fact  that  the  ovum,  if  impregnated,  is  unable  to  survive 
in  the  hostile  environment  of  an  infected  endometrium.  It  is  often 
maintained  that  the  constriction  in  the  uterine  canal  per  se  prevents 
the  entrance  of  spermatozoa,  and  therefore  causes  the  sterility.  This 
in  a  measure  may  be  true  ;  but  endometritis  which  often  results  from 
obstruction  is  the  more  direct  and  frequent  cause  of  sterility. 

Diagnosis  of  Anteflexion. 

Before  the  distinction  was  made  between  physiological  and  patho- 
logical anteflexion,  it  was  usual  to  treat  all  anteflexions  as  pathological. 
The  reaction  came,  and  with  it  a  universal  proposition  that  anteflexion 
had  no  pathological  significance  per  se  ;  that  it  was  wholly  a  question 
of  the  associated  lesions.  But,  like  other  universal  propositions, 
this  one  was  too  sweeping ;  it  did  not  take  into  account  pathological 
anteflexion. 

The  educated  touch  w^hich  distinguishes  the  normal  version,  flexion, 
and  movements  of  the  uterus  will  appreciate  the  anatomical  differences 
between  pathological  and  normal  anteflexion.  The  degree  of  flexure, 
the  mobility  or  rigidity,  and  the  size,  shape,  location,  and  consistence 
of  the  uterus  may  be  ascertained  by  conjoined  manipulation.  The 
presence  of  postuterine  inflammation  is  recognized  by  the  pain  caused 
in  drawing  the  uterus  slightly  forward,  and  by  the  increased  thickness 
and  tenderness  which  may  be  felt  by  vaginal  or  rectal  touch  in  the 
region  of  the  uterosacral  ligaments.  Anteflexion  is  distinguished 
from  myoma  in  the  anterior  wall  of  the  uterus  by  conjoined  examina- 
tion and  the  sound.  The  common  error  of  mistaking  the  normal 
version  and  flexion  of  a  prolapsed  uterus  for  pathological  version  and 
flexion  should  be  avoided. 

Congenital  Anteflexion  will  be  characterized  by  : 

1.  The  small  size  of  the  uterus. 

2.  The  small  or  pin-hole  os  uteri. 

3.  The  relative  lengths  of  the  corpus  and  cervix  uteri ;    the 

corpus  is  one-third  and  the  cervix  is  two-thirds  the  length 


ANTEVERSION  AND  ANTEFLEXION  OF  THE   UTERUS.      Ill 

of  the  entire  uterus.     The  reverse  of  these  measurements  is 
true  of  the  fully  developed  uterus.     See  Chapter  I. 
Acquired  Anteflexion  will  be   recognized  by  one   or  more  of  the 
following  conditions : 

1.  Resisting  bands  behind  the  uterus. 

2.  Downward  and  forward  direction  of  the  cervix  uteri  in  the 

long  axis  of  the  vagina. 

3.  Flexure  of  the  corpus  uteri  upon  the  cervix  ;  the  angle  of 

flexure  is  easily  palpated  in  front  of  the  cervix. 

FiorKE  407. 


Myoma  on  the  anterior  uterine  wall,  simulating  anteflexion. 

Treatment  of  Anteflexion. 

The  treatment  is  directed,  first,  to  the  complications ;  second,  to 
the  mechanical  indications  for  straightening  the  flexed  uterus. 

The  Treatment  of  the  Complications. — If  there  be  inflammation 
of  the  uterus  and  its  surroundings,  in  the  relation  of  either  cause  or 
effect  to  the  displacement,  its  successful  treatment  becomes  the  prime 
indication,  because,  unless  treated,  it  is  a  contraindication  to  the  more 
direct  treatment  of  the  malposition  itself.  It  may  be  necessary  to 
remove  a  tumor  or  to  separate  adhesions.  Incurable  chronic  metritis 
may  render  all  direct  treatment  useless.  Improvement  in  the  general 
health,  treatment  of  other  complications,  and  palliation  then  become 
the  only  resources. 


718  DISPLACEMENTS. 

Before  considering  the  various  recognized  measures  for  the  direct 
treatment  of  the  flexure  itself,  it  is  important  to  exclude  all  cases  of 
normal  anteflexion.  It  would  be  clearly  absurd  to  treat  normal  ante- 
flexion for  dysmenorrhoea  or  sterility. 

The  Mechanical  Indication,  when  the  flexure  is  pathological,  is 
clearly  to  straighten  the  uterus,  so  that  : 

a.  The  uterus  may  be  out  of  the  range  of  the  forces  indicated  by 
the  arrows  in  Figure  405. 

6.  The  circulation  may  be  relieved. 

c.  The  uterine  canal  may  perform  its  natural  functions  as  a  drain- 
age-tube. 

Figure  408. 


Treatment  of  anteflexion  by  massage. 

The  mechanical  treatment  includes  the  following  measures : 

1.  The  pessary. 

2.  Local  massage. 

3.  Electricity. 

4.  Forcible  dilatation. 

5.  Posterior  division  of  the  cervix. 

6.  The  author's  operation. 

1.  The  Pessary. — The  various  anteflexion  and  anteversion  pessaries 
that  have  been  devised  for  the  purpose  of  propping  up  the  corpus 
are  almost  useless.  Their  questionable  reputation  depends  upon  the 
relief  they  frequently  give  to  complicating  prolapse,  the  symptoms 
of  which  have  been  attributed  wrongly  to  anteflexion  and  anteversion. 
If  pessaries  are  indicated  at  all,  therefore,  they  may  be  used  upon 


ANTEVERSION  AND  ANTEFLEXION  OF  THE   UTERUS.       719 


the  same  principle  as  in  descent.  See  Treatment  of  Descent.  Intra- 
uterine stem-pessaries  designed  to  straighten  the  flexed  uterus  are 
sometimes  effective — always  dangerous. 

2.  Local  Pelvic  Massage  applied  during  menstruation  and  in  the  in- 
termenstrual period  has  some  value  for  the  temporary  relief  of  dys- 
menorrhoea  due  to  anteflexion.  The  treatment  consists  of  pushing  the 
cervix  upward  and  backward  with  the  left  index-finger,  while  with 
the  right  hand  a  forward  and  downward  pressure  is  exerted  on  the 
organ  ;  this  converts  for  the  time  the  anteflexion  into  an  extreme  an- 
teversion.     The  method  is  illustrated  by  Figure  408. 

When  the  displacement  is  associated  with  dysmenorrhoea  the  mas- 
sage may  be  continued  during  menstruation,  and  in  some  cases  with 

Figure  409. 


Posterior  division  of  the  cervix  uteri :  lines  of  incision  in  flexion  of  the  uterus. 

Sims'  operation. 

great  and  immediate  relief.     It  should  be  continued  also  for  at  least  a 
number  of  weeks. 

3.  Electricity  is  said  by  the  advocates  of  it  to  be  a  useful  agent ; 
it  is,  however,  by  no  means  effective  enough  to  stand  alone  as  the 
accepted  treatment  of  pathological  anteflexion.  After  considerable 
personal  experience  the  writer  has  discarded  it. 

4.  Forcible  Dilatation. — This  operation,  usually  associated  with 
curettage,  is  described  in  Chapter  Y. ;  it  is  indicated  in  anteflexion 
with  collapsed  or  stenosed  uterine  canal  and  associated  endometritis, 
dysmenorrhoea,  or  sterility. 

The  following  is  an  abstract,  with  some  modifications,  of  a  valuable 
contribution  ^  by  Goodell,  in  which  he  gives  positive  indorsement  to 

1  American  Journal  of  Obstetrics,  p.  1179, 18S4. 


720 


DISPLA  CEMENTS. 


rapid  dilatation  as  proposed  by  Ellinger  and  others.  The  instruments 
used  are  two  Ellinger  dilators,  which  are  recommended  on  account  of 
the  parallel  action  of  their  blades.  The  dilatation  is  begun  with 
the  smaller  instrument  and  completed  with  the  larger.  The  larger 
instrument  has  powerful  blades  that  do  not  spring  nor  feather.  The 
light  instrument  has  only  a  ratchet  in  the  handle  ;  but  the  stronger 
one  has  a  screw  that  forces  the  handles  together  and  the  blades  apart. 
To  prevent  injury  to  the  fundus  when  the  instrument  is  open,  the 

FlGUEE  410. 


The  posterior  wall  of  the  cervix  being  divided  by  scissors. 

length  of  the  blades  is  limited  to  two  inches.  The  larger  instrument 
has  a  dilating  capacity  of  one  and  a  half  inches,  and  has  a  graduated 
arc  in  the  handles  to  indicate  the  divergence  of  the  blades.  GoodelFs 
modification  of  Ellinger's  dilator  is  provided  with  serrated  blades,  to 
keep  them  from  slipping  out  of  the  canal  during  the  process  of  dila- 
tation. 

For  dysmenorrhoea  or  sterility  due  to  flexion  or  stenosis  the  method 
of  operation  is  as  follows  :  A  suppository  containing  a  grain  of  the 


ANTEVEB8I0N  AND  ANTEFLEXION  OF  THE  UTERUS.       721 

aqueous  extract  of  opium  is  introduced  into  the  rectum,  the  patient 
etherized,  and  the  uterus  exposed  by  Sims'  speculum.  The  cervix  is 
held  by  a  tenaculum,  and  the  smaller  dilator  is  introduced  as  far  as  it 
will  go.  Upon  gently  stretching  open  that  portion  of  the  uterine 
canal  which  it  occupies,  the  stricture  above  so  yields  that  when  the 
blades  are  closed  they  will  pass  higher.  By  repeating  this  manoeuvre 
a  cervical  canal  is  tunnelled  out  where  before  not  even  a  fine  probe 
could  be  passed.     Should  the  os  externum  or  cervical  canal  be  too 

Figure  411. 


The  cut  surfaces  held  apart  by  tenacula.  The  dotted  lines  show  wedge-shaped  pieces  to  be 
removed  by  scissors,  in  order  to  make  the  cut  surfaces  more  readily  fold  upon  themselves. 
Sutures  designed  to  fold  cut  surfaces  on  themselves  in  place,  but  not  tied. 


small  to  admit  the  instrument,  a  pair  of  pointed  scissors  may  be  sub- 
stituted, and  by  the  same  opening  and  closing  motions  the  canal  may 
be  prepared  for  the  introduction  of  the  smaller  dilator.  As  soon  as 
the  cavity  of  the  uterus  has  been  entered  the  handles  are  brought 
together.  This  dilator  is  then  withdrawn,  the  larger  one  introduced, 
and  its  handles  slowly  screwed  together.  If  the  flexure  be  very 
marked,  the  larger  instrument,  after  being  withdrawn,  should  be  re- 
introduced with  its  curve   in  the  direction  opposite  to  that  of  the 


722 


DISPLA  CEMENTS. 


flexure,  and  the  final  dilatation  made  with  the  dilator  in  this  posi- 
tion ;  but  in  reversing  the  curve  the  operator  should  take  care  not  to 
rotate  the  organ  upon  its  own  axis,  and  not  to  mistake  a  twist  thus 
made  for  a  reversal  of  the  flexure.  The  ether  is  then  withheld,  and 
the  instrument  allowed  to  remain  in  place  until  the  patient  begins  to 
flinch,  when  it  is  removed.  The  best  time  for  the  dilatation  is  mid- 
way between  the  monthly  periods.  In  the  majority  of  cases  the  dila- 
tation  should  be  carried    to  about  one  and  a  quarter  inches.     The 

FiGTJBE    412. 


Suture  shown  in   Fi^re  405  tied,  and  additional  sutures  desigrned  to  fortify  this  one  also 
introduced  and  tied.    This  ordinarily  completes  the  operation. " 

infantile  uterus  that  has  failed  to  develop  at  puberty  has  thin,  un- 
yielding walls,  and  should  therefore  not  be  dilated  more  than  three- 
fourths  of  an  inch  to  an  inch.  In  using  the  larger  instrument  it  is 
usually  necessary  to  have  the  assistant  make  decided  countertraction 
with  the  vulsella  forceps  to  keep  the  blades  of  the  dilator  from  slip- 
ping out.  The  cervix  is  sometimes  lacerated,  but  not  sufficiently  to 
produce  unpleasant  results.  Goodell's  statistics  include  one  hundred 
and  fifty  operations  of  full  dilatation  under  ether,  with  no  fatal  result 
and  without  serious  inflammatory  disturbance. 


ANTEVERSION  AND  ANTEFLEXION  OF  THE    UTERUS.       723 

After  forcible  dilatation  iinder  ether  the  cervical  canal  may  remain 
relatively  open  and  straight,  and  a  symptomatic  cure  may  he  effected. 
Too  often,  however,  the  canal  returns  to  its  previously  angular  condi- 
tion, and  the  dysmenorrhoea  and  sterility  continue.  The  comparative 
safety  of  forcible  dilatation  in  the  hands  of  a  skilful  and  experienced 
gynecologist  may  be  contrasted  with  its  great  danger  when  undertaken 
by  a  careless  septic  operator  unacquainted  with  the  special  require- 
ments of  uterine  surgery.  Peri-uterine  inflammation  is  considered 
ordinarily  a  contraindication  to  the  operation. 

Dilatation  by  means  of  tents  is  transient  in  its  results  and  danger- 
ous to  life.  The  operation  has  given  frequent  and  serious  warnings, 
in  the  shape  of  pelvic  infections,  which,  if  not  destructive  to  life, 
have  been  overwhelmingly  disastrous  in  their  influence  upon  health. 

5.  Posterior  Division  of  the  Cervix  Uteri  is  an  operation  devised  and 
once  extensively  practised  by  Marion  Sims  and  his  followers  ;  it  was 
designed  to  straighten  the  uterine  canal  by  making  a  direct  outlet 
from  the  point  of  flexure  directly  through  the  posterior  wall  of  the 
cervix.  The  operation  was  not  without  merit,  but  it  fell  into  disre- 
pute because,  first,  it  was  done  often  in  normal  anteflexions ;  and 
second,  because,  while  it  overcame  the  obstruction  in  the  uterine  canal, 
it  did  not  straighten  the  uterus  and  so  relieve  the  more  important 
obstruction  in  the  blood-vessels.  Moreover,  the  divided  cervix  was 
prone  to  reunite  and  leave  a  cicatricial  contraction  at  the  os  externum. 
The  operation  was  in  the  right  direction,  but  was  inadequate. 

6.  The  Author's  Operation,^  about  to  be  described,  has  for  its  object 
the  utilization  of  dilatation  and  of  posterior  division  of  the  cer^nx 
in  such  a  way  as  not  only  to  enlarge  the  calibre  of  the  uterine  canal, 
but  also  to  straighten  the  uterus  and  thereby  overcome  the  circulatory 
obstruction.     The  operation  is  performed  as  follows  : 

Everything  connected  wnth  the  operation  has  been  rendered  surgi- 
cally clean.  The  patient  being  under  ether,  the  uterus  is  exposed  by 
Sims'  speculum.  The  uterine  canal  is  dilated  l^y  means  of  a  Palmer 
dilator,  followed  by  an  Ellinger  dilator,  sufficiently  to  permit  the 
introduction  of  a  small  sharp  curette,  but  not  necessarily  to  the  extent 
advocated  by  Goodell.  Curettage  is  performed  as  directed  in  Chapter 
XVII.  for  endometritis.  The  curettage  may  give  only  negative 
results,  and  may  be,  therefore,  simply  exploratory ;  or  it  may  give 
evidence  of  pronounced  endometritis.  If  the  latter,  it  is  imperative 
as  a  preliminary  aseptic  step,  not  only  to  the  plastic  part  of  the  oper- 
ation, but  also  as  a  curative  measure. 

The  cervix  is  divided  with  scissors  backward  in  the  median  line 
past  the  uterovaginal  attachment  nearly  to  the  uteroperitoneal  fold  in 
the  pouch  of  Douglas.     See  Figure  410. 

The  cut  surfaces  thus  incised  then  are  held  widely  apart  by  means 
of  two  tenacula  in  the  hands  of  an  assistant  ;  the  incision  is  somewhat 
deepened  by  means  of  a  scalpel,  especially  in  the  uterine  wall  next 
to  the  cervical  canal,  and  a  small  angle  is  cut  out  on  either  side,  as 
shown  by  the  dotted  lines  in  Figure  411.     The  cut  surface  on  each 

1 E.  C.  Dudley.  "  A  Plastic  Operation  Desismed  to  Straighten  the  Anteflexed  Uterus." 
American  Journal  of  Obstetrics,  vol.  xxiv.  No.  2, 1891. 


724  DISPLACEMENTS. 

side  is  now  folded  on  itself  by  a  single  silkworm  gut  suture,  as  shown 
in  Figure  411.  This  suture  is  tied  and  fortified  by  interrupted 
sutures  on  either  side.  The  lines  of  union  thus  made  are  shown  in 
Figure  412.  By  means  of  these  sutures  the  os  externum  is  carried 
directly  back  to  the  angle  of  the  incision.  The  cervix  now  points 
backward  in  its  normal  direction  toward  the  hollow  of  the  sacrum, 
instead  of  forward  toward  the  vaginal  outlet.     See  Figure  403. 

In  some  cases  of  extreme  anteflexion  there  is  a  disproportionately 
long  anterior  lip,  which  is  the  result  of  a  relatively  greater  pressure 

FiGTJEE  413. 


Anterior  lip  excised  and  sutures  in  place  ready  to  tie. 

on  the  posterior  lip  by  the  posterior  vaginal  wall ;  this  elongated  lip 
should  be  caught  with  the  tenaculum  and  partially  removed  by  the 
scissors.  The  incised  surface  is  then  closed  upon  itself  with  sutures  as 
shown  in  Figures  41.3  and  414.  The  dotted  line  in  Figure  405  shows 
in  section  the  line  of  incision  through  the  protruding  lip ;  the  incision 
should  extend  to,  but  not  into,  the  os  externum.  This  part  of  the 
operation  is  not  required  unless  the  anterior  lip  decidedly  protrudes, 
and  therefore  usually  is  omitted.     The  removal  of  a  portion  of  the  lip 


ANTEVERSION  AND  ANTEFLEXION  OF  THE   UTERUS.       725 

in  a  suitable  case  is  not  only  not  a  mutilation,  but  it  even  contributes 
to  the  straightening  of  the  uterus. 

Conjoined  examination  upon  completion  of  the  operation  in  each  of 
the  author's  cases  has  shown  invariably  the  uterus  either  to  have  been 
straightened  or  the  anteflexion  to  have  been  reduced  to  a  degree  quite 
within  physiological  limits.  The  results  have  been  substantially  the 
same  whether  the  point  of  flexure  was  at  the  os  internum  or  below  it. 

Figure  414. 


Sutures  tied  and  operation  complete,  both  on  posterior  and  anterior  lips. 


The  two  posterior  lines  of  sutures  have  the  efiect  of  transplanting 
the  OS  externum  to  the  very  angle  of  the  posterior  incision.  The  an- 
terior sutures,  if  used,  have  the  effect  of  carrying  the  cervix  back  by 
a  distance  equal  to  one-half  the  length  of  the  anterior  cut  surface, 
which  is  doubled  upon  itself.  By  these  means  a  permanent  change, 
quite  equal  to  overcoming  the  flexure,  is  effected  in  the  direction  of 
the  cervix.  As  the  result  of  the  anterior  portion  of  the  operation, 
the  uterus  in  a  suitable  case  is  lifted  also  in  a  higher  plane  in  the 

44 


726  DISPLACEMENTS. 

pelvis,  where  it  ceases  to  be  a  mechanical  irritant  to  the  bladder. 
This  portion  of  the  operation  may  therefore  be  indicated  for  descent 
when  complicated  with  anteflexion. 

The  writer  has  not  undertaken  this  operation  on  the  small,  unde- 
veloped infantile  uterus.  The  so-called  congenital  anteflexion  is  only 
one  factor  in  a  general  failure  of  development,  a  failure  that  pertains 
not  to  the  uterus  and  other  reproductive  organs  alone,  but  to  the  gen- 
eral system.  The  amenorrhoea  or  very  scanty  menstruation  and  the 
sterility  usually  associated  with  this  condition,  being  only  the  local 
expressions  of  faulty  general  development,  are  not  reached  by  any 
uterine  treatment,  surgical  or  non-surgical. 

This  operation  was  published  first  in  November,  1890,^  At  that 
time  the  writer  reported  eighteen  cases.  The  results  were  classified 
under  two  heads,  one  for  the  mechanical  and  one  for  the  symptomatic 
results.  The  mechanical  result  was  invariably  a  satisfactory  straight- 
ening of  the  uterus.  The  symptoms  were  relieved  satisfactorily  in 
about  three-fourths  of  the  cases.  The  author's  personal  experience 
with  this  operation  now  numbers  about  one  hundred  cases.  Witli  this 
larger  experience  and  larger  observation  of  the  symptomatic  results 
he  is  able  to  verify  the  conclusions  formed  when  the  operation  was 
given  to  the  profession.  In  no  case  has  the  operation  failed  to  give 
an  anatomical  cure,  and  the  symptomatic  results  have  been  satisfactory 
in  about  75  per  cent,  of  all  cases. 

The  symptomatic  indication  in  the  great  majority  of  cases  was  dys- 
menorrhoea.  This  symptom,  when  the  flexure  was  uncomplicated  by 
peri-uterine  inflammation^ — that  is,  when  the  conditions  were  mechan- 
ical— has  been  quite  generally  relieved.  In  seven  cases  the  indication 
was  prolonged  sterility.  In  three  of  these  cases  normal  parturition 
has  taken  place. 

R.  G.  Wadsworth,^  of  Boston,  reports  31  cases  for  which  the  ope- 
ration was  performed  by  himself  and  other  operators  in  the  Free 
Hospital  for  Women,  in  Boston,  and  10  cases  occurring  in  the  private 
practice  of  Dr.  Reynolds,  and  37  cases  from  the  literature.  Generally 
speaking,  the  results  of  the  operation  for  all  these  cases,  both  ana- 
tomically and  symptoraatically,  were  substantially  the  same  as  for  the 
series  of  cases  originally  reported  by  the  author. 

The  operation  is  not  presented  as  a  panacea  for  all  the  maladies  of 
pelvic  origin  in  which  there  happens  to  be  a  pathological  anteflexion. 
Cases  are  numerous  in  which  anteflexion  is  rather  an  incidental  than 
an  essential  factor.  The  hope  is  that  the  operation  may  prove  of  value 
when  the  indication  to  be  fulfilled  is  wholly  or  in  part  mechanical. 

There  is  danger  that  this  operation  will  be  performed  indiscrimi- 
nately in  cases  not  of  pathological,  but  of  physiological  anteflexion. 
On  the  other  hand,  those  who  do  not  consider  anteflexion  as  having 
any  pathological  significance  per  se,  and  do  not  always  make  the  dis- 
tinction between  the  physiological  and  pathological  position,  will  fail 
to  appreciate  the  mechanical  indication,  and  will  therefore  discard  the 
operation  altogether.     Clearly  a  woman  might  have  anteflexion  and, 

1  Paper  by  E.  C.  Dudley,  read  before  the  New  York  Obstetrical  Society,  November  18, 1890. 

2  The  Bulletin  of  the  Free  Hospital  for  Women. 


ANTEVERSION  AND  ANTEFLEXION  OF  THE   UTERUS.       727 

if  it  were  normal,  might  have  a  large  variety  of  lesions  wholly  inde- 
pendent of  it.  To  say  this,  after  all,  might  be  saying  only  that  a 
woman  may  have  a  variety  of  pathological  developments  in  the  pelvis, 
and  at  the  same  time  have  the  uterus  in  its  normal  position.  Normal 
anteflexion  could,  of  course,  have  no  pathological  significance. 

Since  the  investigations  of  Schultze  and  others,  we  may  distinguish 
downright  pathological  anteflexion,  in  which  the  uterus  is  bent  to  the 
point  of  producing  two  kinds  of  obstruction  at  the  angle  of  flexure : 
1.  Obstruction  of  the  canal  from  collapse  of  the  canal.  2.  Obstruction 
of  the  blood-vessels  from  collapse  of  the  blood-vessels.  Under  such 
conditions  uterine  congestion  and  catarrh,  as  pointed  out  in  the  fore- 
going paragraphs,  are  apt  to  follow;  normal  physiological  changes 
cannot  take  place  either  in  the  decidua  of  menstruation  or  in  the 
decidua  of  pregnancy ;  hence,  menstrual  disorders  and  sterility. 

The  mechanical  indication  is  clear:  straighten  the  uterus  and 
thereby  relieve  the  obstruction  in  both  the  uterine  canal  and  the  vessels. 

The  operation  is  not  a  substitute  for  dilatation  and  curettage,  but 
rather  supplementary  to  these  two  procedures. 

The  writer  has  practised  extreme  divulsion  with  curettement  in 
many  cases  of  anteflexion  ;  but  the  results  were  not  very  satisfactory. 
They  are,  however,  more  gratifying  when  the  plastic  operation  already 
described  is  added  to  the  dilatation  and  curettage. 

If  it  is  wrong  to  treat  anteflexion  mechanically,  because  it  is  a 
result  of  certain  associated  lesions,  it  follows  that  retroflexion  and  all 
other  displacements  should  not  be  treated  mechanically,  because  they 
also  are  equally  the  result  of  associated  lesions.  This  almost  amounts 
to  the  reductio  ad  absurdum 

One  hears  much  of  inflammation  of  the  uterosacral  ligaments  as 
the  great  associated  lesion  in  pathological  anteflexion,  and  yet  is  disap- 
pointed often  in  his  search  for  evidence  of  such  inflammation.  In- 
flammation often  exists  there,  but  in  a  large  proportion  of  such  cases 
it  has  passed  away,  leaving  pathological  anteflexion  as  a  permanent 
result. 

In  a  few  cases  of  anteflexion  low  down  in  the  cervix  the  author 
with  good  anatomical  and  symptomatic  results  has  substituted 
Schroeder's  operation  for  his  own. 

TORSION  OF  THE  UTERUS. 

Any  part  or  the  whole  of  the  uterus  may  turn  on  its  own  axis — 
that  is,  be  twisted  upon  itself. 

Causes  of  Torsion  of  the  Uterus. 

The  causes  of  this  displacement  are  : 

1.  Anteflexion  associated  with  contraction  of  one   uterosacral 

ligament. 

2.  Retroflexion. 

3.  Uterine  tumors. 

4.  Tumors  of  the  uterine  appendages. 

5.  Double  uterus ;  one  horn  may  lie  anterior  to  the  other. 


728  DISPLACEMENTS. 


Diagnosis  and  Treatment  of  Torsion  of  the  Uterus. 

Torsion  of  the  uterus  may  be  recognized  by  conjoined  examina- 
tion which  will  demonstrate  the  anterior  surface  of  the  uterus  lying, 
not  directly  in  front,  but  to  one  side.  The  long  axis  of  the  uterus 
generally  is  found,  not  in  the  median  line,  but  having  a  diagonal 
direction  across  the  pelvis.  The  treatment  is  that  of  the  causative 
complications. 


CHAPTER    XLIX. 

INVERSION  OF  THE  UTERUS.     HERNIA  OF   THE  UTERUS 

AND  OVARY. 

INVERSION  OF   THE   UTERUS. 

Inversion  of  tlie  uterus  is  the  partial  or  complete  turning  of  the 
organ  inside  out.  The  diiference  between  partial  and  complete  inver- 
sion is  simply  one  of  degree.  In  partial  inversion  some  part  of  the 
wall  of  the  corpus  uteri,  usually  the  fundus,  is  depressed  into  the 
uterine  cavity,  but  the  organ  does  not  protrude  through  the  external 
OS  into  the  vagina.  In  complete  inversion  the  uterus  has  turned  com- 
pletely inside  out.  The  inverted  uterus  is  then  inside  the  vagina,  or, 
if  the  vagina  is  also  inverted,  both  organs  will  be,  to  quote  Hip- 
pocrates, between  the  thighs,  " velut  scrotum."'  Figures  415-424. 
represent  the  incomplete  and  complete  forms  of  inversion. 

Etiology  of  Inversion  of  the  Uterus. 

More  than  10  per  cent,  of  all  cases  are  puerperal.  The  causes 
usually  assigned  are  traction  on  the  cord  in  the  delivery  of  the  placenta, 
traction  in  the  rapid  delivery  of  the  child,  traction  by  gravity  of  intra- 
uterine tumors,  or  traction  exerted  in  their  delivery.  These  causes, 
however,  are  all  inadequate  to  produce  the  accident  unless  the  muscular 
walls  of  the  uterus  are  predisposed  by  relaxation.  Paralysis  or  great 
relaxation  of  the  uterine  wall  is  the  essential  cause  of  the  accident. 
Undue  importance  has  been  given  to  the  various  forms  of  traction ; 
even  coughing  or  sneezing  may  invert  a  very  relaxed  uterus.^ 

Inversion  in  the  majority  of  cases  occurs  spontaneously  as  a  direct 
result  of  paralysis  of  uterine  muscles.  This  paralysis  may  pertain  to 
any  part  or  all  of  the  uterine  wall,  but  is  usually  most  pronounced  at 
the  placental  site.  The  paralyzed  portion  is  depressed  first  into  the 
uterine  cavity,  so  as  to  give  the  corpus  uteri  the  appearance  of  the 
bottom  of  a  junk  bottle.  The  unin verted  portion  of  the  muscular 
wall,  not  being  paralyzed,  may  contract  and  seize  the  partially  in- 
verted paralyzed  portion,  and  push  it  down  further  and  further  until 
inversion  is  complete. 

The  conditions  that  most  favor  paralysis  and  relaxation  of  the  mus- 
cular layers  are  not  wholly  known.  The  accident  in  about  88  per  cent, 
of  all  cases  is  associated  with  childbirth;^  hence  the  inference  that  the 
most  active  causes  are  connected  wnth  utero-gestation  and  parturition. 
In  a  small  proportion  of  cases  inversion  has  followed  distention  of  the 


1  Hippocrates.    From  Thomas  and  Mund6. 

2  Adaptation  from  Thomas  and  Mund(5.    Diseases  of  Women. 

3  Crosse.    Loc.  cit. 


729 


730 


DISPLA  CEMENTS. 


endometrium  by  retained  fluids  or  tumors.     The  hemorrhage,  often 
associated  with  muscular  relaxation  of  the  uterus,  is  not  a  cause,  but  a 


Figure  415. 


Acute  case,  uterus  inverted  completely  into  vagina:  O  0,  ovaries ;  T  2',  Fallopian  tubes; 
P,  placenta  still  attached  to  uterus.  Openings  of  Fallopian  tubes  through  inverted  fundus 
are  shown  in  section. 


result  of  the  relaxation.      Finally,  we  may  say  that  the  condition  in  a 
large  proportion  of  cases  arises  without  definite  assignable  cause.    The 


INVERSION  OF  THE   UTERUS.  731 

Figure  416.  Figure  417.  Figure  41S. 


Figure  416.— Partial  iaversion  of  the  left  horn  of  the  uterus. 

Figure  417.— Myoma  simulating  partial  inversion  at  the  left  horn  of  the  uterus. 

Figure  418. — Partial  inversion  of  the  uterus  complicated  by  and  caused  by  a  myoma. 


Figure  419. 


Figure  420. 


Figure  421. 


Figure  419. — Partial  inversion  of  the  uterus  :  the  fundus  is  at  the  os  externum. 

Figure  420.— Pedunculated  myoma  protruding  from  the  os  externum,  resembling  an 
inverted  fundus  uteri. 

Figure  421.— Slight  inversion  of  the  fundus  uteri  with  pedunculated  uterine  myoma  pro- 
truding through  the  os  externum  and  resembling  inversion.  , 


Figure  422. 


Figure  423. 


FiGui5E  424. 


Figure  422.— Complete  inversion  of  the  uterus  complicated  by  a  myoma  in  the  peritoneal 
cavity,  which  has  all  the  physical  appearance  of  a  uterus.  There  Is  difficulty  in  .such  a  case  in 
determining  which  is  the  uterus  and  which  is  the  myoma. 

Figure  423.— The  uterus  is  inverted  completely  into  the  vagina. 

Figure  424.— The  reverse  of  Figure  422. 


732  DISPLACEMENTS. 

accident  occurred  at  the  Rotunda  Hospital  but  once  in  190,800,  and 
at  the  Vienna  Lying-in  Hospital  but  once  in  250,000  deliveries.^ 

A  most  instructive  case  has  been  recorded  by  Willard  Parker,  as 
follows : 

"A  young  woman,  who  had  borne  one  child  seven  or  eight  years 
previously,  and  had  never  had  any  recognized  uterine  disease,  while 
making  a  violent  eifort  in  rolling  tenpins  suddenly  felt  something 
give  way  within  her,  after  which  she  suffered  the  most  intense  pain 
and  became  completely  disabled.  Dr.  Parker,  being  called  to  see  her, 
after  a  hasty  examination  coincided  with  the  opinion  of  the  attending 
physician,  that  a  polypus  had  been  suddenly  expelled  and  was  hanging 
in  the  vagina.  Impressed  with  this  belief,  he  removed  the  whole 
mass,  when,  to  his  surprise,  he  found  in  his  hands  the  inverted  uterus 
with  its  tubes  and  ligaments.  The  patient  recovered  without  any  bad 
symptoms,  and  subsequently  menstruated  regularly."^ 

The  occasional  occurrence  of  spontaneous  replacement  of  a  uterus 
that  had  been  inverted  has  been  observed  repeatedly,  and  is  a  fact  no 
less  remarkable  than  spontaneous  inversion.  In  one  case  replacement 
occurred  while  the  patient  was  straining  at  stool. ^ 

Mechanism  of  Inversion  of  the  Uterus. 

If  the  entire  uterine  walls  are  paralyzed,  the  organ  may  invert  as 
the  result  of  traction  or  coughing  or  sneezing,  or  of  its  own  weight. 
Intra-abdominal  force  from  above  may  push  the  paralyzed  uterine 
wall  through  the  os  externum  into  the  vagina.  If  the  paralysis  per- 
tains to  only  a  part  of  the  uterine  wall,  the  inversion,  as  already 
explained,  may  occur  by  contraction  of  the  non-paralyzed  portion. 
Clearly,  inversion  cannot  take  place  when  the  entire  uterine  wall  is 
active.  It  may,  however,  do  so  when  the  paralysis  is  partial  and  the 
activity  is  partial.  Regional  paralysis,  as  already  stated,  is  more  apt 
to  occur  at  the  placental  site,  where  the  wall  is  thinner  and  softer.  It 
more  frequently  occurs  at  the  fundus  or  at  one  of  the  horns. 

In  some  cases  the  inversion  takes  place  from  below  upward — that 
is,  the  relaxed  cervical  portion  comes  down  as  in  prolapse  of  the  anus. 
This  process  begins  as  eversion,  and  continues  until  the  whole  organ 
is  inverted. 

Anatomy  and  Pathology  of  Inversion  of  the  Uterus. 

The  inversion,  if  not  complete,  may  have  been  arrested  at  any  point. 
Thus  the  inverted  portion  may  be  above  the  internal  or  external  os ; 
or  it  may  consist  of  the  entire  uterus  rolled  out  into  the  vagina ;  or, 
together  with  the  inverted  vagina,  the  inverted  uterus  may  be  out- 
side of  the  vulva.  The  exposed  uterine  mucosa  is  then  dark  red  or 
purple  from  congestion,  and  there  may  be  regional  ecchymosis,  ero- 
sion, and  ulceration.     Adhesions  have  been  known  to  form  between 

»Playfair  and  Allbutt.    System  of  Gynecology.       2  Thomas  and  Mund6.    Diseases  of  Women. 
2  Thomas.    Diseases  of  Women. 


INVERSION  OF  THE   UTERUS.  733 

the  wholly  extruded  uterus  and  the  vagina.  The  writer  has  observed 
one  case  in  which  such  adhesions  had  formed  between  the  partially 
inverted  corpus  and  the  cervical  mucosa. 

There  is  hemorrhage  from  the  extruded  and  inflamed  uterine 
mucosa.  In  the  combined  inversion  of  the  uterus  and  vagina  the 
mucosa,  after  long  exposure  to  external  influences,  may  become  dry, 
wrinkled,  and  parch raent-1  ike,  as  does  the  vagina  in  complete  pro- 
cidentia of  the  uuinverted  uterus ;  the  two  conditions  have  been 
mistaken  for  one  another. 

The  vessels  are  strangulated,  circulation  is  impeded,  the  nutrition 
of  the  organ  suffers,  and  some  degree  of  infection  is  almost  inevitable. 
In  rare  instances  gangrene  and  sloughing  of  the  inverted  portion  have 
taken  place. 

The  uterine  ligaments,  Fallopian  tubes,  ovaries,  and  even  intestine 
may  at  first  be  drawn  into  the  peritoneal  cup  of  the  inverted  organ. 
Rarely  these  organs  become  adherent  within  the  cup ;  usually  with 
returning  uterine  activity  and  contraction  they  are  expelled  and 
remain  outside. 

Symptoms  of  Inversion  of  the  Uterus. 

The  symptoms  of  acute  complete  inversion  of  sudden  occurrence 
are  as  follows : 

Fixed  intense  pain. 
Profuse  hemorrhage. 
Shock  and  collapse. 
Partial  inversion  may  occur  with  no  characteristic  symptoms,  and, 
without  physical  examination,  may  escape  notice. 

Chronic  inversion  may  have  developed  slowly,  or  may  follow  acute 
inversion  ;  it  causes  : 

Mechanical  disorders  of  the  urinary  organs  and  rectum. 
Hemorrhage,  more  or  less  profuse,  and  consequent  anaemia. 
Bloody,  purulent,  or  serous  discharges. 
Difficulty  in  walking  and  standing. 
Pelvic  pain. 
Nerve  exhaustion  and  impaired  health  necessarily   follow.     Life 
may  be   destroyed  slowly  by  the  exhaustive  drain,  or  at  any  time 
rapidly  by  acute  peritonitis.     In  rare   instances,  especially  after  the 
menopause,  there  may  be  only  slight  inconvenience  or  none  at  all. 

Diagnosis  of  Inversion  of  the  Uterus. 

If  the  abdominal  walls  are  relaxed  and  thin,  and  permit  adequate 
palpation  of  all  the  intrapelvic  organs,  conjoined  examination  will 
show  :  first,  the  absence  of  a  part  or  a  whole  of  the  uterus  in  the 
place  where  it  normally  belongs ;  and,  second,  its  presence  inverted 
partially  or  wholly  in  the  vagina  or  in  the  uterine  canal.  The  con- 
cavity or  peritoneal  depression  caused  by  the  inversion  sometimes  may 
be  felt  through  the  abdominal  wall.     Rectal  touch  or  combined  rectal 


734  DISPLACEMENTS. 

and  vaginal  touch,  with  the  hand  over  the  abdomen  or  the  sound  in 
the  bladder,  may  facilitate  the  diagnosis.  The  finger  in  the  rectum 
may  be  made  to  meet  the  hand  over  the  abdomen  or  the  sound  in  the 
bladder,  and  thereby  demonstrate  the  absence  of  a  uterus  above  the 
vagina.  The  orifices  of  the  Fallopian  tubes,  now  rolled  out  and  ex- 
posed, also  may  be  demonstrable.  In  case  of  rigid  thick  abdominal 
walls  the  diagnosis  will  be  more  difficult. 

The  differential  diagnosis,  in  a  given  case,  may  raise  two  questions: 
First,  Is  the  protruding  mass  a  uterine  myoma  or  polypus,  or  a  vag- 
inal tumor  ■?     Second,  Is  it  a  prolapsed  uterus  ? 

Is  it  complete  inversion  ?  ]  Is  it  myoma  or  polypus  f 

1.  No  pedunculated  attachment  to  uterus.  1.  Attached  to  the  uterine  wall  by  broad  sur- 

1  face  or  by  narrow  pedicle. 


2.  Uterine    cavity  being  obliterated,  sound  |     2.  Sound   passes    by  the  side  of    the  mass 
can  be  passed  but  short  distance  in  incomplete 
and  not  at  all  in  complete  inversion. 

3.  Vaginal  or  rectal  conjoined  examination 
shows  a  ring  or  depression  where  the  uterus 
should  be,  and  fails  to  show  the  uterus  above 
the  vagina. 

4.  The    inverted  uterus    is    a   symmetrical 


pyriform  body.  ,  asymmetrical. 


through  external  os  far  into  the  uterine  cavity. 

3.  Uterus  felt  above  vagina. 

4.  Not  usually  symmetrical  and  may  be  very 


5.  Orifices    of  the    Fallopian  tubes   usually 
demonstrable. 

6.  Muciparous  glands  of  the  uterus  present  , 
and  microscopically  demonstrable.  j  developed. 


Not  present. 
6.  Not  present,  or  if  present    less  perfectly 


Is  it  incomplete  inversion  o'"  the  uterus  f 


Is  it  an  intra-uterine  myo'nia  f 


1.  The  uterine  cavity  as  measured  by  the  ,     1.  Cavity  enlarged, 
sound  will  be  diminished. 

2.  Development  usually  sudden.  !     2.  Development  gradual. 

3.  Bimanual    examination    shows  ring-like  |     3.  Uterus  symmetrical  or  asymmetrical,  but 
depression  in  wall  of  uterus.  I  no  ring-like  depression. 

4.  Usually  dates  from  parturition.  J     4.  No  parturition. 

The  great  difficulty  in  some  cases  of  making  the  difPerential  diag- 
nosis between  a  polypus  or  myoma  and  an  inverted  uterus  is  em- 
phasized by  the  fact  that  deservedly  eminent  surgeons  have  extirpated 
the  partially  or  wholly  inverted  uterus  repeatedly  under  the  mistaken 
diagnosis  of  a  myoma.  Conversely,  the  effiDrt  has  been  made  to  reduce 
a  supposedly  inverted  uterus  when  the  extruding  mass  was  a  myoma. 
The  author  personally  recalls  a  case  at  the  Woman's  Hospital  in  the 
city  of  New  York,  upon  which  such  an  attempt  was  made  per- 
sistently by  T.  G.  Thomas. 

In  rare  cases  the  diagnosis  has  been  obscured  by  the  presence  of  an 
inverted  uterus  in  the  vagina,  and  by  the  coexistence  of  a  subperi- 
toneal myoma  of  the  size,  shape,  consistence,  and  position  of  a  normal 
uterus.  The  distinction  between  the  two  bodies  might  then  depend 
solely  upon  the  presence  or  absence  of  the  orifices  of  the  Fallopian 
tubes  in  the  vaginal  mass.  Ordinary  care  and  intelligence,  however, 
usually  will  enable  the  surgeon  to  avoid  serious  mistakes.  Velpeau, 
quoted  l)y  Simpson,  once  sagely  remarked,  however,  that  in  some  cases 
doubt  is  the  only  rational  opinion. 

The  differential  diagnosis  between  inversion  and  procidentia  uteri 
usually  will  be  easy. 


INVERSION  OF  THE   UTERUS.  735 


Is  it  inversio  uteri  ? 


1.  The  protruding  mass  is  wider  below  than 
above. 

2.  External  os  uteri  absent  and  tubal  orifices 
present  at  lower  end  of  mass. 

3.  Sound  ill  urethra  goes  upward  into  blad- 
der away  from  mass.  , 

Exception.— When  the  vagina  is  concurrently 
inverted  the  sound  may  pass  downward.  j 

4.  Obliteration  of  vaginal  fornices.  '      4.  Obliteration  of  vaginal  fornices. 


7s  it  complete  procidentia  uteri  f 
Mass  wider  above. 


2.  External  os  present  and  tubal  openings 
absent. 

3.  Sound  goes  downward  into  bladder,  but 
also  into  anterior  portion  of  mass. 


In  the  diagnosis  and  differential  diagnosis,  inspection  and  conjoined 
examination  and  the  sound  furnish  the  most  reliable  information. 

Prognosis  of  Inversion  of  the  Uterus. 

If  replacement  can  be  effected  promptly  in  the  acute  stage  just 
after  the  occurrence  of  the  accident,  the  prognosis  is  immediately 
good.  If  replacement  be  delayed  until  rigid  contraction  renders  it 
more  difficult,  the  prognosis  will  be  correspondingly  more  serious. 
The  possible  dangers  arising  from  acute  inversion  are  from  hemor- 
rhage, shock,  collapse,  and  acute  infection. 

Chronic  inversion,  unless  relieved  by  replacement,  is  likely  to  destroy 
health — if  not,  indeed,  life — by  slow,  exhaustive  hemorrhages,  uterine 
discharges,  and  consequent  ansemia.  Nervous  exhaustion  from  sur- 
gical efforts  to  replace  the  organ,  and  the  possibility  of  its  removal  by 
mistake  for  a  myoma,  are  positive  sources  of  danger.  Acute  infection 
and  peritonitis  are  among  the  always  dreaded  possibilities.  Few 
authentic  cases  of  spontaneous  reposition  have  been  recorded. 

In  rare  instances  the  inverted  uterus  gives  little  or  no  trouble,  even 
when  associated  with  complete  vaginal  inversion  ;  the  uterine  and 
vaginal  mucosa  possibly  may  undergo  changes  to  make  them  resemble 
skin,  the  surfaces  becoming  hard,  tough,  parchment-like,  and  wrinkled. 
Finally,  hemorrhages  may  cease,  and  the  woman  may  live  to  old  age 
in  comparative  comfort. 

Treatment  of  Acute  Inversion  of  the  Uterus. 

Puerperal  inversion  usually  takes  ])lace  in  the  presence  of  the 
attendant  between  the  birth  of  the  child  and  the  delivery  of  the 
placenta,  and  may,  therefore,  in  the  acute  stage  be  recognized  while 
uterine  walls  still  are  relaxed  sufficiently  to  permit  immediate 
replacement. 

If  the  placenta  still  is  attached,  it  should  be  removed  rapidly. 
Under  anaesthesia  the  hand  then  is  introduced  into  the  vagina  and 
the  fundus  pushed  up  through  the  cervical  canal  into  place.  Strong 
contractions,  with  alternating  relaxations,  are  usual  in  this  stage. 
Reduction  by  taxis  is  almost  impossible  during  the  contractions. 
Instead,  therefore,  of  handling  or  kneading  the  organ  to  reduce  its 
size  by  contraction,  the  attendant  waits  patiently  for  relaxation,  and 
then  makes  a  steady,  firm,  and  prompt  effort  at  replacement.  The 
whole  corpus  may  be  carried  up  at  once  or  it  may  be  necessary  with 
the  finger-tips  to  indent  the  fundus  at  some  point,  preferably  one  of 
the  cornua,  and  let  this  be  the  starting-point  of  the  replacement. 


736  DISPLACEMENTS. 

Hot  water  and  a  fountain  syringe,  or,  better,  a  Davidson  syringe  of 
interrupted  current,  should  be  ready,  in  order  that  while  the  hand  is 
still  in  the  uterine  cavity  a  hot  douche  may  be  thrown  rapidly  into  the 
uterus.  The  hot  water,  by  its  stimulating  effect,  sets  up  strong  uniform 
uterine  contraction ;  this  controls  hemorrhage  and  prevents  recur- 
rence of  inversion.  The  hot  water  uterine  douche  in  the  control  of 
post-partum  hemorrhage  acts  in  the  same  way.  Within  a  few  hours 
after  the  accident  firm  uterine  contraction  or  retraction  takes  place  in 
the  muscular  walls  of  the  inverted  uterus.  When  such  retraction 
once  is  established,  replacement  usually  will  be  quite  as  difficult  as  if 
the  condition  had  existed  for  months — that  is,  the  change  from  acute 
to  chronic  inversion  is  rapid. 

Treatment  of  Chronic  Inversion  of  the  Uterus. 

Until  a  comparatively  recent  time  the  inverted  uterus,  once  con- 
tracted, was  regarded  incurable  except  by  hysterectomy.  On  the 
possibility  of  replacing  an  inverted  uterus  after  the  organ  had  con- 
tracted, the  late  Charles  D.  Meigs,  of  Philadelphia,  in  his  letters  to 
the  students  of  his  class,  in  1846,  wrote  :  "  You  might  as  well  attempt 
to  invert  one  of  the  non-gravid  uteri  on  my  lecture-table  as  to  reposit 
this  one.     The  time  for  replacement  has  gone  by."^ 

The  Obstacles  to  Reposition  are  these  : 

1.  Great  rigidity  in  the  contracted  cervical  ring. 

2.  Increase  in  the  volume  of  the  corpus  uteri  from  congestion. 
This  occurs  soon  after  inversion. 

3.  Later  increased  firmness  and  hardness  in  the  uterine  structures 
from  involution. 

4.  The  mobility  of  the  organ  and  the  difficulty  of  opposing  above 
sufficient  counterpressure  to  the  force  applied  below  in  the  effort  to 
replace. 

5.  Adhesions,  rare  but  possible,  between  the  sides  of  the  peritoneal 
cup. 

Methods  of  Reposition. — The  difficulty  of  overcoming  the 
obstacles  outlined  above  is  apparent  from  the  manifold  methods  that 
have  been  practised  by  different  surgeons.  The  lesson  to  be  learned 
from  the  combined  experience  of  these  methods  is  that  success  is 
attained  best  by  firm,  steady,  continuous,  elastic  pressure,  and  that  it 
may  depend  finally  upon  very  prolonged  and  patient  effort. 

The  object  is  to  overcome  the  rigidity  in  the  cervical  ring.  The 
pressure  to  accomplish  this  may  be  unyielding  or  elastic.  The  treat- 
ment includes  the  following  possible  procedures  : 

1.  Replacement  by  the  unaided  hands. 

2.  Replacement  by  the  hands  aided  by  incisions  or  instruments. 

3.  Continued  elastic  pressure. 

4.  If  reduction  prove  impossible,  the  final  resort  is  hysterectomy. 
If  one  method  fails,  a  combination  of  two  or  more  methods  may 

succeed. 

1  Emmet.    Principles  and  Practice  of  Gynecology. 


INVERSION  OF  THE   UTERUS. 


737 


r 


Preparatory  Treatment. — It  is  always  possible  in  the  course  of 
an  attempt  at  reposition  that  emergencies  may  arise  that  will  necessi- 
tate abdominal   or  vaginal  section  ;  hence,  the  necessity  of  making 


FiGUBE  425. 


Manual  reposition  of  an  inverted  uterus. 


preparation  for  those  operations.  See  Chapter  II.  In  addition  to 
the  above,  iron  may  be  required  for  anaemia,  and  hot  water  or  asep- 
tic gauze  tamponade  in  the  vagina  may  be  needed  for  hemorrhage. 


738 


DISPLA  CEMENTS. 


In  a  very  anseniic  case  several  weeks  or  even  months  of  recuperative 
treatment  may  be  essential. 

Reposition  with  the  Hands,  Emmet's  Method.^ — The  patient, 
anaesthetized,  is  in  the  lithotomy  position.  The  left  hand  is  passed 
into  the  vagina,  the  fingers  and  thumb  are  forced  as  far  as  possible 
into  the  angle  of  reflexion,  so  as  to  encircle  the  part  of  the  corpus 
uteri  that  is  close  to  the  constricted  cervical  ring.  The  fundus  is  in 
contact  with  the  palm  of  the  hand,  and  is  pressed  firmly  upward  by  it, 
while  the  fingers  are  separated  to  their  utmost  to  open  the  cervix.  At 
the  same  time  the  right  hand  behind  the  pubes  slides  the  abdominal 
wall  back  and  forth  over  the  peritoneal  depression.  Tliis  effort,  the 
object  of  which  is  to  open  out  the  contracted  ring,  is  put  forth  con- 


FiGUEE  426. 


Reposition  of  the  inverted  uterus  by  the  method  of  J.  H.  Tate.  The  left  index-finger  is  in 
the  bladder  having  been  passed  from  the  vagina  to  the  bladder  through  a  vesicovaginal  fistula 
made  for  the  purpose.    The  right  index-fluger  is  in  the  rectum. 

tinuously.  Finally,  the  rigid  cervix  uteri  may  begin  to  dilate,  the 
corpus  may  grow  shorter,  and  the  extent  of  inversion  may  lessen 
proportionately.  After  the  corpus  has  been  forced  partially  within 
the  cervix  by  steady  upward  pressure,  the  tips  of  tlie  fingers  are 
brought  together  as  a  wedge,  passed  through  the  os,  and  made  to  com- 
plete the  reposition. 

Emmet's  method  is  much  facilitated  by  keeping,  for  a  few  days 
previous  to  replacement,  a  widely  distended  Barnes  elastic  bag  in  the 
vagina.  The  bag  is  secured  firmly  by  a  T-bandage.  This  dilates  the 
vagina,  makes  room  for  the  hand,  and,  by  the  elastic  upward  pressure 

»  Log.  cit. 


INVERSION  OF  THE   UTERUS.  739 

which  it  exerts,  may  dilate  the  constricted  ring  or  even  by  itself  effect 
replacement.  In  one  case  complete  reposition  was  made  by  Emmet's 
method  in  three  hours  and  fifty-five  minutes. 

Emmet  further  suggests  in  case  of  partial  reposition,  when  the  cor- 
pus uteri  has  been  passed  inside  the  external  os,  that  the  progress  thus 
made  be  secured  by  temporary  closure  of  the  external  os  with  sutures. 

Tate's  Method  of  Taxis.^ — The  index-  and  middle  fingers  of  the 
right  hand  are  passed  into  the  rectum,  and  the  index-finger  of  the 
left  hand  into  the  bladder  through  the  dilated  urethra.  The  balls  of 
the  thumbs  make  constant  firm  pressure  over  the  fundus,  while  the 
fingers  in  the  rectum  and  bladder  make  counterpressure  against  the 
cervix.  In  this  way  great  force  is  applied  more  directly  to  the  con- 
stricted ring  than  by  any  other  method.  In  a  case  of  forty  years' 
standing  reported  by  Tate,  the  thumbs  soon  indented  the  fundus,  the 
cervix  began  to  dilate,  the  corpus  was  pushed  through  the  cervix,  and 
reduction  was  accomplished  in  a  few  minutes.  Were  it  not  for  the 
danger  of  rupture  of  the  urethra  and  consequent  permanent  incon- 
tinence of  urine,  this  method  would,  perhaps,  have  the  preference 
over  all  others.  Every  serious  objection  could,  however,  be  over- 
come by  opening  the  vesicovaginal  septum  and  passing  the  finger 
through  the  artificial  vesicovaginal  fistula  thus  made,  instead  of 
the  urethra.  The  fistula,  after  reposition,  could  be  closed  with 
little  difficulty  or  loss  of  time,  and  with  practically  no  additional 
danger.^ 

There  are  numerous  other  methods  of  reduction  by  taxis,  but 
they  involve  no  valuable  principle  not  included  in  those  already 
mentioned. 

Elastic  Pressure  by  the  Water-bag-  or  Colpeurynter  has 
been  mentioned  in  the  preparation  for  Emmet's  method.  It  is 
called  colpeurysis.  Figure  427.  Reposition  may  be  begun  by  de- 
pressing with  the  fingers  one  horn  of  the  uterus,  and  the  depressed 
portion,  if  forced  onward,  serves  as  a  wedge  to  dilate  the  con- 
tracted cervix.  The  hand  after  a  time  becomes  fatigued  and  use- 
less. Colpeurysis  then  may  be  substituted  and  long-sustained  elastic 
pressure,  interrupted  occasionally  by  attempts  at  manual  replacement, 
may  be  effective.  In  many  cases  elastic  pre-ssure  alone  will  suffice. 
There  is,  however,  no  short  limit  to  the  time  during  which  it  may  be 
necessary  to  continue  it.  In  some  cases  reposition  finally  has  been 
made  only  after  two  or  three  weeks  of  constant  effort,  the  rubber 
bag  filled  with  water  being  held  constantly  in  place  against  the  in- 
verted fundus  uteri  by  means  of  a  tight  bandage,  so  that  it  will  exert 
constant  pressure. 

An  effective  mode  of  using  elastic  pressure  is  that  described  by 
Thomas  and  Munde.^  Through  a  Sims  speculum  place  a  tampon  of 
aseptic  gauze  soaked  with  glycerin  firmly  around  the  cervix.  This 
keeps  the  uterus  from  slipping  out  of  the  line  of  pressure.  Shave 
the  pubes.  Introduce  a  large  rubber  bag  into  the  vagina  and  fill  it 
with  water.     Cut  a  strip  of  adhesive  plaster  two  and  a  half  inches 

1 .1.  H.  Tate.    Cincinnati  Lancet  and  Observer,  March,  1878     Emmet. 

2  SuRffested  by  Kmmet.    Principles  and  Practice  of  Gynecology. 

3  Diseases  of  Women,  p.  454. 


740 


DISPLA  CEMENTS. 


wide,  long  enough  to  reach  from  the  lumbar  region,  between  the 
thighs,  over  the  pubes  up  to  the  navel,  There  are  two  openings  in 
the  plaster,  one  for  transmission  of  the  tube  of  the  rubber  bag  and  one 
for  the  urethra.  The  plaster  is  cut  in  two  just  over  the  vulva,  and 
that  portion  from  the  vulva  to  the  anus  lined  with  a  layer  of  gauze. 


Figure  427. 


The  colpeurynter. 


The  two  parts  of  the  plaster  are  held  together  by  three  safety-pins, 
and  may  be  opened  during  defecation  or  urination  ;  the  urine  if  neces- 
sary is  drawn  by  a  catheter.  The  pressure  may  be  increased  by 
tightening  the  plaster  or  pumping  in  more  water ;  it  may  be  decreased 
by  loosening  the  plaster  or  drawing  out  water  through  the  stop-cock  on 
the  tube.  The  patient  is  kept  in  bed,  and  pain  is  controlled  by  opium 
or  morphine. 


INVERSION  OF  THE   UTERUS. 


741 


*  Continued  elastic  pressure  by  colpeiirysis  is  sometimes  not  tolerated, 
or  it  may  be  contraindicated  by  the  presence  of  inflammation.  Then 
anaesthesia  and  more  energetic  measures  may  be  indicated. 

The  Spiral  Spring  (White's)  Method.— A  rapid  and  for  many 
cases  effective  method  of  elastic  pressure  is  that  of  the  spiral  spring 
attached  to  a  rubber  cup.  Emmet's  method  may  be  reinforced  effec- 
tively by  the  use  of  this  instrument.  Figure  428.  The  patient  is 
anaesthetized.  The  left  hand  in  the  vagina  grasps  the  inverted  corpus 
uteri,  and  at  the  same  time  holds  the  fundus  in  the  rubber  cup.  Pro- 
jecting outward  from  this  cup  is  a  slightly  curved  rod,  having  a 
strong  spiral  spring  attached  to  its  end.  The  operator's  body  rests 
against  the  spiral,  and  through  it  exerts  pressure  upon  the  uterus. 
The  disengaged  hand  is  used  for  counterpressure  behind  the  pubes, 
as  already  described  in  Emmet's  method.  Figure  428  shows  the  in- 
strument.    Two  or  more  hours  of  continuous  effort   may  be  required 


Figure  42 


White  spiral  spring  repositor  :  A,  rubber  cup;  B,  rod  connecting  cup  with  spring;  C,  spiral 

spring. 


to  reach  the  result.  Numerous  other  similar  instruments  have  been 
devised,  but  none  more  effective  than  this. 

Incision. — When  the  various  forms  of  taxis,  supplemented  by 
gradual  or  rapid  elastic  pressure,  fail,  the  rigidity  of  the  cervix  may 
be  overcome  by  incision.  This  plan  was  suggested  by  the  fact  that, 
after  forcible  dilatation,  the  cervix  was  usually  more  or  less  torn,  and 
that  an  incision  would  be  preferable  to  a  tear.  Various  forms  of 
incision  have  been  advocated  or  practised  by  James  Y.  Simpson, 
J.  Marion  Sims,  Barnes,  Matthews  Duncan,  and  others.  One 
method  is  to  draw  down  the  corpus  and  cut  nearly  or  quite  through 
the  constricted  cervical  wall  at  one  or  more  jwints,  and  then  reduce 
the  inversion  by  taxis  or  rapid  elastic  pressure.  The  favorite  in- 
cisions are  one  in  the  anterior  and  one  in  the  posterior  wall  of  the 
cervix. 

J.  Bernard  Browne,  of  Baltimore,'  makes  an  incision  through  the 
fundus.  A  strong  dilator  then  is  passed  through  the  opening  into  the 
constricted  ring,  and  the  cervix  is  dilated  until  the  corpus  can  be 
forced  through  into  place.  Just  before  reposition  the  wound  in 
the  corpus  is    closed   with   catgut  sutures.     If  asepsis  be  thorough. 


1  New  York  Medical  Journal,  November  24, 188?. 


45 


742 


DISPLA  CEMENTS. 


intra-uterine  gauze  drainage  may  be  used  iu  place  of  closing  the 
opening. 

These  and  similar  methods  of  incision  before  the  days  of  aseptic 
surgery  were  regarded  as  extra  hazardous,  and  therefore  were  disap- 
proved generally.  Under  aseptic  conditions,  however,  the  danger 
would  doubtless  be  less  than  formerly  was  supposed.  With  an  asep- 
tic field  of  operation  and  thorough  gauze  drainage  in  the  uterus,  the 
risk  should  not  l)e  greater  than  that  of  other  operations  involving  peri- 
toneal incisions  of  equal  extent. 

The  method  of  Thomas  to  open  the  abdomen,  and  especially  that 
of  Kiistner  to  open  from  the  vagina  into  Douglas's  pouch,  in  order  to 
reach  and  directly  dilate  the  cervix  on  the  peritoneal  side,  have  fallen 
into  unmerited  discredit. 

Hysterectomy. — If  all  efforts  of  taxis,  elastic  pressure,  and  inci- 
sion have  failed,  removal  of  the  uterus  may  become  a  final  re- 
source. The  operation  ordinarily  would  be  vaginal  hysterectomy,  and 
would  be  performed  substantially  as  already  described  for  cancer. 
The  writer  suggests  that  after  the  posterior  and  anterior  incisions  have 
been  made  from  the  vagina  into  the  peritoneal  cavity,  another  attempt 
at  reposition  be  made.  Through  these  openings  great  force  could  be 
applied  by  the  mechanical  principle  employed  in  the  method  of  Tate. 
The  fingers  should  be  introduced  not  into  the  rectum  and  vagina,  but 
through  the  vaginal  incisions.  Counterpressure  then  could  be  made 
most  powerfully  direct  against  the  cervical  ring. 


HERNIA    OF    THE   UTERUS    AND    OVARY. 

A  common  form  of  hernia  of  the  uterus  has  been  described  in  the 
chapter  on  Descent  of  the  Uterus. 

Hysterocele,  or  hernia  of  the  uterus  through  the  inguinal  canal  or 
inguinal  rings,  is  a  rare  and  remaiJ^able  displacement.  Cases  have  been 
reported  by  Olshausen,  Leopold,  Rectorzik,  Winckel,  and  Scanzoni, 
of  diplacement  of  the  uterus  into  the  sac  of  a  crural  or  inguinal  hernia.^ 
In  two  cases  the  displacement  was  complicated  by  pregnancy,  which 
continued  to  the  fourth  month. 

The  Diagnosis  is  based  upon  the  absence  of  the  uterus  from  its 
normal  place  and  the  presence  in  the  hernial  sac  of  a  body  answering 
its  description.  If  pregnant,  the  uterus  will  increase  progressively 
in  size  until  relieved  by  abortion. 

The  Treatment  is  the  same  as  for  any  other  form  of  hernia.  If 
reduction  by  taxis  is  unsuccessful,  herniotomy  becomes  necessary, 
and  may  involve  removal  of  the  uterus. 

Hernia  of  the  ovary  may  occur  in  the  same  way  as  hernia  of  the 
uterus,  and  is  subject  to  the  same  principles  of  diagnosis  and  treat- 
ment. The  author  personally  has  seen  but  one  case ;  that  was  treated 
successfully  by  herniotomy  and  removal  of  the  ovary. 

»  Thomas  and  Munde.    Diseases  of  Women. 


PART  VI. 

DISORDERS    OF    MENSTRUATION    AND 
STERILITY^  AND  INCONTINENCE  OF  URINE. 


CHAPTER    L. 

PREMATURE  MENSTRUATION  AND  PROTRACTED 
MENSTRUATION. 

PREMATURE   MENSTRUATION. 

It  is  clear  that  precocious  menstruation  could  not  occur  unless  the 
genital  organs  had  developed  prematurely  ;  and  that  in  the  absence  of 
such  development  there  would  be  no  evidence  except  flow  of  blood  on 
which  the  fact  of  menstruation  could  be  established.  One  should  be 
cautious  in  drawing  conclusions  from  the  mere  presence  of  a  red  stain 
on  the  napkin  or  clothing  for  such  a  stain  is  not  proof  of  menstrua- 
tion; it  may  be  blood  from  vulvovaginitis,  urethritis,  or  traumatism, 
or,  what  is  more  frequent,  from  deposit  of  red  urates. 

Development  of  the  sexual  organs  has,  in  rarely  exceptional  cases, 
taken  place  long  before  the  age  of  puberty,  and  in  some  instances  has 
been  observed  at  infancy.  Perfectly  developed  mammae,  a  full  growth 
of  hair  on  the  mons  veneris,  much  development  of  the  external  gener- 
ative organs,  and  great  precocity  of  the  internal  organs  have  been 
observed  in  infancy  and  in  early  childhood.  In  many  instances  of 
precocious  development  premature  menstruation  did  not  occur ;  in 
others  it  made  its  appearance  several  years  before  the  normal  age  of 
puberty  ;  and  in  one  or  two  attested  cases  apparently  physiological 
menstruation  occurred  soon  after  birth. 

As  above  stated,  the  appearance  of  a  bloody  discharge,  even  though 
it  be  periodical,  is  not  necessarily  to  be  attributed  to  menstruation. 
Such  a  discharge  may  occur  as  the  result  of  tumors,  erosions,  ulcer- 
ations, and  other  pathological  causes,  at  any  period  of  life,  from  infancy 
to  old  age. 

The  evidence  of  many  notable  examples  of  early  pregnancy  is 
unquestioned;  Croom  tabulated  from  the  literature  a  series  of  twelve 

»  The  disorders  of  menstruation  and  sterility  are  merely  functional,  and  therefore  must  be 
considered,  not  as  diseases,  but  as  symptoms.  In  studying  these  symptoms  it  is  essential  to 
consider  them  from  the  standpoint  of  the  multiform  lesions  that  cause  them.  There  is  scarcely 
a  gynecological  disease  that  may  not  have  relation,  direct  or  remote,  with  functional  disorders. 
Part  VI.,  in  a  certain  sense  therefore,  is  an  index  to  the  whole  subject  of  gynecology.  In  con- 
nection with  the  study  of  these  disorders,  it  will  be  profitable  to  read  the  "first  chapter  of  the 
book,  which  contains  a  condensed  statement  of  the  phenomena  of  menstruation. 

743 


744  DISORDERS  OF  MENSTRUATION  AND  STERILITY. 

cases  in  which  pregnancy,  occurring  in  girls  of  ages  varying  from 
eight  to  thirteen  years,  resulted,  with  one  exception,  in  the  delivery 
of  mature  infants. 

Causes  of  Premature  Menstruation. 

The  causes  of  precocious  sexual  development  and  premature  men- 
struation, especially  in  infantile  cases,  are  not  satisfactorily  explained. 
Among  the  alleged  causes  are:  1,  heredity;  2,  immoral  associations, 
which  viciously  direct  the  attention  of  the  child  to  the  generative 
organs ;  3,  masturbation ;  4,  ascarides  in  the  rectum  and  other  para- 
sites about  the  external  genitals ;  5,  uncleanliness,  especially  the  de- 
position of  caseous  secretions  about  the  clitoris ;  6,  neoplasm  of  the 
generative  organs ;  7,  undue  nervous  and  mental  excitement. 

Treatment  of  Premature  Menstruation. 

The  treatment  is  implied  in  the  preceding  paragraph ;  it  consists 
in  the  removal  of  the  cause.  The  necessity  for  cleanliness  and 
chastity  is  self-evident.  A  young  girl  prone  to  precocity  should  be 
guarded  against  all  influences  that  tend  to  stimulate  the  emotions  or 
to  provoke  sexual  excitation.  The  treatment  is  rather  regulative 
than  medicinal,  is  chiefly  hygienic,  and,  as  such,  includes  careful 
attention  to  diet,  exercise,  recreation,  sleep,  and  study. 

PROTRACTED    MENSTRUATION. 

The  normal  menopause  usually  takes  place  between  the  ages  of 
forty-five  and  fifty  years ;  it  may  occur  earlier,  or  as  late  as  the  fifty- 
third  year ;  but  cessation  of  menstruation  before  the  fortieth  year  or 
the  continuance  of  it  later  than  the  "fifty-second  year  W'Ould  be  pre- 
sumptive evidence  of  a  pathological  cause.  Apparently  normal  men- 
struation, however,  has  been  known  to  continue  until  after  the  age  of 
fifty-seven.  The  coexistence  of  ovulation  with  late  menstruation  in 
a  given  case  can  be  established  only  by  the  occurrence  of  pregnancy ; 
of  this  occurrence  little  satisfactory  proof  has  been  recorded  after  the 
fifty-second  or  at  most  the  fifty-fourth  year.  The  evidence  is  con- 
clusive, therefore,  that  these  ages  are  the  practical  limit  of  possible 
fertility.^  The  author  observed  a  case  of  tubal  pregnancy  in  a  wo- 
man, fifty-four  years  old. 

1  Allbutt  and  Plaj'fair.    System  of  Gynecology. 


CHAPTER    LI. 

AMENORRHCEA  AND  SCANTY  MENSTRUATION. 
AMENORRHCEA. 

Amenorrhcea  is  the  absence  of  menstruation.  The  subject  is 
restricted  here  to  amenorrhcea  dependent  upon  pathological  or  surgical 
causes,  and  excludes  the  physiological  absence  of  menstruation 
before  puberty,  during  gestation  and  the  puerperium,  and  after  the 
menopause  ;  it  also  excludes  all  cases  in  which  menstrual  fluid,  having 
been  retained  by  atresia  in  the  genital  tract,  fails  to  make  its  appear- 
ance.    See  Chapter  XXXVIII. 

Classification. 

Two  general  divisions  of  amenorrhcea  have  been  recognized :  1. 
The  disorder  may  be  due  to  absence  of  the  reproductive  organs  or  to 
failure  of  those  organs  to  develop  from  the  immaturity  of  infancy 
to  the  maturity  of  puberty.  2.  Menstruation  may  have  been  estab- 
lished at  puberty,  and  from  pathological  causes  may  have  ceased. 
These  two  divisions  are  designated  as  primary  and  secondary  amen- 
orrlioea. 

Etiology  of  Amenorrhcea. 

The  causes  may  be  divided  into  : 
I.  Local  causes. 
II.  General  causes. 

I.  Local  Causes. — Chief  among  the  local  causes  are  absence,  im- 
perfect development,  and  atrophy  of  the  uterus  and  its  appendages. 
The  relative  extent  of  these  defects  may  be  greater  in  the  uterus  and 
less  in  the  appendages  ;  or  greater  in  the  appendagesand  less  in  the 
uterus.  Absence  or  imperfect  development  of  the  genitals  may  coexist 
with  perfect  development  of  the  body  in  general.  There  are  two 
forms  of  uterine  atrophy :  concentric,  in  which  the  uterus  is  much 
contracted  and  its  canal  correspondingly  shortened  ;  and  excentric,  in 
which  the  atrophic  process  has  resulted  in  a  thinning  of  the  walls 
without  decrease  in  the  length  of  the  uterine  canal. 

Endometritis  and  metritis,  especially  when  associated  with  an  in- 
fectious puerperium,  may  give  rise  to  atrophy  of  the  uterus  and  con- 
sequent amenorrhcea.  See  Chapter  XYIII.  Ovaritis  may,  as  a  cause 
of  atrophy  of  the  ovary,  produce  the  same  result.  Microcystic  degen- 
eration of  the  ovaries  and  ordinary  bilateral  ovarian  cysts  are  asso- 
ciated frequently  with  atrophy  of  the  ovary  and  amenorrhcea. 

745 


746  DISORDERS  OF  MENSTRUATION  AND  STERILITY. 

Atrophy  of  the  uterus  and  ovaries,  especially  of  the  former,  has 
been  observed  occasionally  to  follow  sharp  curettage  for  endometritis. 

II.  General  Causes  seldom  produce  amenorrhoea  by  acting  directly 
jper  se  ;  they  usually  do  so  indirectly  by  causing  atrophy  of  the  uterus 
or  ovaries,  or  of  both.     They  may  be  classified  as  follows  : 

1.  Acute  infectious  diseases. 

2.  Chronic  disorders. 

3.  Nervous  disorders. 

1.  Acute  Infectious  Diseases  include  scarlatina,  diphtheria,  typhoid 
fever,  and  arthritic  rheumatism.  The  same  infection  that  produces 
these  diseases  may  produce  also  atrophy  of  the  uterus  or  ovaries, 

2.  Chronic  Disorders. — Among  the  chronic  disorders  that  cause 
amenorrhoea  are  tuberculosis,  diabetes,  syphilis,  anaemia,  nephritis, 
chlorosis,  myxoedema,  malaria,  and  exophthalmic  goitre.  Amenorrhoea 
associated  with  these  disorders  may  not  be  consequent  upon  atrophy ; 
it  may  be  simply  an  effort  of  nature  to  conserve  the  blood  and  strength 
of  a  woman  whose  general  nutrition  would  suffer  even  from  slight  men- 
struation. In  some  cases  anaemia  is  associated  with  uterine  hemor- 
rhage.    See  Chapter  LII. 

3.  Nervous  and  Mental  Disorders. — The  psychoses,  especially  those 
causing  great  mental  depression,  are  likely,  with  or  without  atrophy 
of  the  uterus,  to  be  associated  with  amenorrhoea.  The  influence  of  the 
nervous  system  is  manifest  in  the  amenorrhoea  of  prisoners  and  in- 
mates of  asylums.  Sudden  emotion,  chill,  and  fright  have  been 
known,  temporarily  or  permanently,  to  arrest  menstruation. 

In  addition  to  the  above  causes  may  be  mentioned  the  following  : 
excessive  hemorrhage,  especially  from  the  genitals  ;  superinvolution 
of  the  uterus  from  prolonged  lactation  ;  tissue-change  of  unknown 
origin;  the  morphine-habit;  and  faulty  hygiene,  especially  such 
hygiene  as  comes  from  insufficient  food,  overwork,  and  vitiated  air. 

Adiposity  in  aneemic  women  is  often  the  cause  of  amenorrhoea ;  the 
menstrual  disorder,  however,  sometimes  disappears  with  removal  of 
the  cause.  The  physiological  amenorrhoea  of  the  menopause  is  fol- 
lowed not  uncommonly  by  deposition  of  fat. 

The  amenorrhoea  of  delayed  puberty  may  occur  in  girls  whose 
generative  organs  are  apparently  well  developed.  Failure  to  men- 
struate in  such  cases  may  be  due  to  one  or  more  of  the  general  causes 
already  outlined.  In  some  cases  of  apparently  robust  health  the  patient, 
for  reasons  unknown,  fails  to  menstruate.  The  girl  may  at  the  period 
of  puberty  menstruate  normally,  and  after  a  year  or  two  may  men- 
struate less  and  less,  and  perhaps  finally  cease  altogether.  In  too 
many  such  cases  the  amenorrhoea  is  due  doubtless  to  diversion  of 
energy,  which  should  be  used  in  the  building  up  of  the  reproductive 
system,  to  social  and  mental  requirements.  If  this  energy  is  diverted 
to  the  brain  or  to  the  ball-room,  the  reproductive  system  may 
suffer. 

Removal  of  the  ovaries  in  the  great  majority  of  cases  will  arrest 
menstruation  immediately.  The  causes  of  continued  menstruation 
after  double  ovariotomy  are :  1,  the  presence  of  a  supernumerary 
ovary  not  observed  ;  2,  failure  to  remove  all  of  the  ovarian  tissue ; 


AMENOBRHCEA  AND  SCANTY  MENSTRUATION.  747 

3,  failure  to  remove  the  tubes  close  into  the  horns  of  the  uterus; 

4,  diseases  of  the  -uterus,  i.  e.,  endometritis,  carcinoma,  and  fibroids  ; 

5,  persistence  of  habit. 

Symptoms  of  Amenorrhoea. 

Absence  of  menstruation  is  the  prime  symptom ;  associated  with 
this  may  be  numerous  disturbances  referable  to  the  nervous  system  ; 
among  them,  defective  vision,  ringing  in  the  ears,  hysteria,  paresis, 
sweating,  and  such  skin-eruptions  as  acne,  urticaria,  eczema,  and  her- 
pes. Amenorrhoea  often  is  associated  with  all  the  symptoms  of  men- 
.struation  except  the  flow— these  symptoms  taken  together  are  termed 
the  molimen. 

Vicarious  menstruation  is  an  infrequent  occurrence.  Isumerous 
remarkable  cases,  however,  have  been  reported  in  which  a  periodic 
flow  of  blood  from  some  organ  other  than  the  uterus  apparently 
took  the  place  of  normal  menstruation.  Such  a  flow  may  come  from 
the  nose,  ear,  bowel,  or  bronchi,  or  from  any  exposed  surface,  such 
as  an  ulcer  ;  it  may  be  accompanied  by  a  discharge  of  milk  from 
the  breasts  or  with  diarrhoea.  The  cause  of  vicarious  menstruation 
is  unknown. 

Diagnosis  of  Amenorrhoea.. 

Inasmuch  as  amenorrhoea  is  a  symptom,  and  not  a  disease,  the 
object  of  diagnosis  must  be  to  recognize  the  lesion  or  lesions  that 
underlie  and  perpetuate  the  symptom.  Amenorrhoea,  especially  that 
caused  by  atrophy  of  the  ovaries,  is  characterized  sometimes  by  the 
presence  of  a  peculiar  menstrual  molimen  above  mentioned,  unaccom- 
panied by  a  flow  of  blood,  but  attended  with  great  ovarian  hypogastric 
and  lumbar  pain. 

Prognosis  of  Amenorrhoea. 

The  prognosis  is  that  of  the  lesion  that  produces  the  amenor- 
rhoea. Primary  amenorrhoea,  due  to  absence  of  the  uterus  or  ovaries, 
is  permanent.  Full  development  of  the  rudimentary  organs  and  con- 
sequent menstruation  have  been  reported  in  rare  instances  ;  but  these 
reports  are  not  sufficientlv  definite  to  have  practical  significance. 

Excentric  atrophy  of  the  uterus,  that  does  not  decrease  the  length 
of  the  organ,  but  only  thins  its  walls,  may,  on  removal  of  the  cause 
and  the  establishment  of  correct  hygiene,  terminate  in  anatomical 
and  physiological  recovery  ;  concentric  atrophy,  m  which  the  uterus 
is  contracted  uniformly,  is  permanent.  As  a  rule  atrophy  due  to  in- 
fection, especially  to  an  infectious  puerperium,  is  permanent. 

Amenorrhoea  due  to  prolonged  lactation,  or  to  nervous  causes, 
such  as  sudden  fright  or  violent  emotion  or  chill,  offers  a  favorable 

prognosis.  .        ... 

In  general,  the  prospect  of  recovery  is  good  for  all  cases  m  which 
atrophv  of  the  uterus  or  ovaries  is  only  a  participation  in  a  general 
system'ic  failure  of  nutrition.     In  cases  of  defective  local  development 


748  DISORDERS  OF  MENSTRUATION  AND  STERILITY. 

and  of  atrophy  due  to  local  causes,  especially  to  infection,  the  amen- 
orrhoea  is  usually  permanent.  In  the  class  of  cases  mentioned  under 
etiology,  in  which  girls  in  apparently  robust  health  fail  to  menstruate  at 
puberty,  the  prognosis  is  not  necessarily  bad,  for  in  many  such  cases 
normal  menstruation  and  maturity  occur  after  marriage,  and  in  some 
such  cases  pregnancy  has  been  observed  even  though  the  amenorrhcea 
persisted. 

Treatment  of  Amenorrhcea. 

The  treatment  must  vary  with  the  cause.  Certain  forms  of  amen- 
orrhcea, mentioned  under  Prognosis,  are  permanent,  and  therefore  in- 
curable. 

The  curable  cases  are  usually  those  in  which  the  uterus  or 
ovaries  have,  because  of  some  wasting  disease,  such,  for  example,  as 
tuberculosis,  failed  to  perform  their  functions.  Amenorrhcea  then 
may,  as  already  stated,  be  only  an  eflPort  of  nature  to  conserve  the 
woman's  blood  and  strength.  The  ill-health  should  not  be  attributed 
to  want  of  menstruation,  but  to  general  want  of  nutrition  ;  under 
such  conditions  treatment  designed  to  re-establish  menstruation  by 
local  stimulation  is  clearly  contraindicated.  Such  treatment  Avould 
defeat  the  efforts  of  nature  and  still  further  exhaust  the  M^oman's 
vitality  and  strength.  The  treatment  should  be  not  local,  but 
systemic. 

Systemic  Treatment. — It  follows,  from  the  foregoing,  that 
systemic  treatment  must  be  that  of  the  numerous  causal  diseases 
already  mentioned,  such  as  anaemia,  chlorosis,  myxoedema,  exophthal- 
mic goitre,  malaria,  nephritis,  and  tuberculosis.  Among  the  most 
reliable  medicinal  remedies  are  iron,  arsenic,  manganese,  the  bitter 
tonics,  salines,  and  mineral  waters.  Hygienic  remedies,  such  as 
nutritious  food,  exercise,  rest,  bathing,  and  suitable  climate,  must 
have  adequate  attention. 

In  amenorrhcea  due  to  obesity  and  associated  anaemia  the  indica- 
tion is  to  improve  nutrition  by  cure  of  the  anaemia  and  reduction  of 
the  fat. 

The  distressing  nervous  symptoms  mentioned  in  Chapter  I.,  that 
sometimes  follow  the  menopause,  should  be  treated  on  general  prin- 
ciples. The  treatment  indicated  for  these  symptoms  is  the  same 
whether  the  menopause  occurs  from  natural  causes  or  is  produced 
artificially  by  removal  of  the  uterine  appendages.  Ovarian  extract 
in  three  grain  doses,  taken  three  times  a  day,  apparently  has  given 
much  relief. 

Local  Treatment  is  generally  useless.  In  some  cases  it  appears 
to  have  been  effective  ;  but  the  improvement  probably  resulted  from 
general  nutritional  changes.  Pelvic  congestion  sometimes  associated 
with  suppression  of  the  menses  may  be  relieved  by  rest  in  bed,  regu- 
lation of  the  bowels,  hot  water  vaginal  douche  (see  Chapter  IV.), 
glycerin  tamponade  in  the  vagina,  scarification  and  leeching  of  the 
cervix.  Pelvic  anaemia  associated  with  amenorrhcea  is  an  indication 
for  pelvic  massage  and  gymnastics. 


AMENORRHCEA  AND  SCANTY  MENSTRUATION.  749 

Electricity  applied  to  the  pelvic  organs,  whether  from  the  ordi- 
nary battery  or  from  the  zinc  and  copper  pessary,  is  of  questionable 
value. 

SCANTY   MENSTRUATION. 

Scanty  menstruation,  like  menorrhagia,  is  a  relative  condition.^ 
The  normal  flow  may  vary  for  different  women  between  two  and  six 
days — that  is,  a  flow  of  two  days'  duration,  for  example,  may  be 
normal  for  a  woman  who  cannot  afford  to  lose  much  blood,  while  for 
a  very  plethoric  woman  a  much  longer  period  of  flow  might  be  nor- 
mal. A  material  decrease  or  increase,  however,  in  the  number  of 
days  or  in  the  amount  normal  for  a  given  individual  should  give  rise 
to  suspicion  of  a  pathological  cause.  The  woman's  menstrual  habit 
therefore  must  be  considered  in  the  diagnosis. 

The  causes  of  scanty  menstruation  are  identical  with  those  already 
laid  down  as  the  causes  of  amenorrhoea ;  the  same  etiology  being 
established,  it  follows  that  the  pathology,  diagnosis,  and  treatment 
must  also  be  along  the  same  lines. 

1  Groom.    System  of  Gynecology,  AUbutt  and  Playfair. 


CHAPTER     LII, 


UTERINE  HEMORRHAGE— MENORRAGIA  AND  METROR- 
RHAGIA. 

Menorrhagia  is  excessive  loss  of  blood  from  abnormally  pro- 
fuse or  abnormally  prolonged  menstruation.  Loss  of  blood  from  the 
uterus  in  the  interval  between  the  end  of  one  menstruation  and  the 
beginning  of  the  next,  whether  scanty  or  profuse,  is  known  as  metror- 
rhagia. Hemorrhage  from  such  causes  as  placenta  prsevia,  degenera- 
tion of  the  chorion,  and  inversion  of  the  uterus,  is  described  in  works 
on  obstetrics. 

The  terras  menorrhagia  and  metrorrhagia,  although  in  general  use, 
cannot  be  applied  always  with  accuracy.  The  menstrual  flow  may  be 
prolonged  throughout  the  greater  part  of  the  month,  or  may  cease 
altogether  for  intervals  of  hours  or  days.  It  is  therefore  evident  that 
menstrual  hemorrhage — menorrhagia — and  intermenstrual  hemor- 
rhage— metrorrhagia — may  be  indistinguishable.  It  is  quite  as  well 
to  use  the  more  simple  term,  uterine  hemorrhage. 

Etiolog-y  of  Uterine  Hemorrhage. 

Certain  disorders  which,  if  present,  are  apt  to  cause  uterine  hemor- 
rhage will  he  found  described  more  fully  in  other  parts  of  the  book 
that  specially  treat  of  them.  Among  the  more  common  of  these  con- 
ditions are  : 

1.  Inflammations.  4.  Foreign  bodies. 

2.  Tumors.  5.  Systemic  disorders. 

3.  Displacements.  6.  Visceral  diseases. 

7.  Uterine  moles. 

1.  Inflammations. — The  inflammatory  causes  of  uterine  hemor- 
rhage may  be  uterine  or  extra-uterine. 

Uterine  Inflammations. — Chronic  glandular  endometritis,  as  de- 
scribed in  Chapter  XVI.,  is  characterized  by  enlargement  of  the 
glandular  and  vascular  structures  of  the  endonietrium,  and  by  conse- 
quent excessive  glandular  secretion  or  hemorrhage,  or  both  combined. 
From  the  pathology,  therefore,  it  is  easy  to  understand  that  an  exces- 
sive flow  due  to  endometritis  is  mixed  ordinarily  with  glandular  secre- 
tions ;  that  these  secretions  may  form  a  very  considerable  part  of  the 
abnormal  menstrual  discharge  ;  and  that  in  some  cases  in  which  the 
disease  is  more  glandular  than  vascular  the  discharge  may  be  almost 
entirely  a  profuse  uterine  leucorrhoea  composed  of  vitiated  mucus  or 
mucopus,  and  only  slightly  admixed  with  blood.  Such  a  discharge, 
if  profuse,  even  though  it  contains  no  blood,  may  be  quite  as  exhaust- 
ing as  if  it  were  of  a  pronounced  hemorrhagic  character. 

Arteriosclerosis  of  the  uterine  vessels  alone  has  been  assigned  as 

750 


UTERINE  HEMORRHAGE.  751 

the  cause  of  uncontrollable  uterine  hemorrhage  by  Herman,  August 
Martin,  Keinscke,  and  Kiistner.  After  a  careful  review  of  the  few 
recorded  cases,  Findley  concludes  that  arteriosclerosis,  per  se,  is  not 
an  adequate  cause  of  uterine  hemorrhage.  In  all  the  reported  cases 
there  were  other  conditions  which  had  resulted  in  obstruction  to  the 
general  circulation,  such  as  Bright's  disease,  heart  lesions,  pulmonary 
infection,  and  thrombosis  of  the  uterine  vessels.  In  the  case  recorded 
by  Findley  arteriosclerosis  and  calcification  of  the  uterine  vessels 
undoubtedly  existed  long  before  the  beginning  of  the  hemorrhage. 
In  this  case  embolic  infarction  of  the  uterus  from  a  thrombus  in  the 
heart  was  the  immediate  cause  of  hemorrhage.^  See  Chronic  Metritis. 
Extra-uterine  Inflammations,  such  as  ovaritis,  salpingitis,  parame- 
tritis, and  perimetritis,  give  rise  to  pelvic  congestion  and  to  a  conse- 
quent effort  of  nature  to  obtain  relief  by  an  increased  flow.  Ovaritis, 
according  to  its  nature,  may  increase  or  diminish  menstruation. 
Parenchymatous  inflammation  in  the  cortical  substance  of  the  ovary 
may  increase  the  flow.  On  the  contrary,  the  atrophic  process  of 
interstitial  ovaritis  or  of  microcystic  degeneration  of  the  ovary,  tends 
to  induce  amenorrhoea, 

2.  Tumors. — Uterine  tumors  cause  excessive  menstruation  in 
greater  or  less  degree  according  to  their  situation.  A  growth  begin- 
ning in  close  relation  with  the  endometrium  and  developing  within 
the  uterine  cavity  may  set  up  a  dangerous  periodical  or  constant 
bleeding ;  if  situated  in  the  uterine  wall,  between  the  endometrium 
and  the  perimetrium,  it  may  excite  little  more  than  the  normal  flow ; 
located  near  the  peritoneal  covering,  it  may,  especially  if  peduncu- 
lated, give  rise  to  no  menstrual  excess  whatever  :  uterine  myoma,  for 
example,  may,  according  as  it  is  submucous,  intramural,  or  subperi- 
toneal, cause  much,  little,  or  no  menorrhagia.     See  Chapter  XXVI. 

A  tumor  may  set  up  excessive  flow  in  one  or  both  of  two  ways :  1. 
The  irritation  of  its  presence  may  give  rise  to  a  hemorrhagic  endome- 
tritis. 2.  Ulcerative  processes  or  friability  of  the  tumor  itself  may 
cause  rupture  of  blood-vessels  and  hemorrhage.  In  one  way,  the 
blood  comes  from  the  endometrium  ;  in  the  other,  from  the  tumor. 
Myomata,  being  slow  to  ulcerate  and  break  down,  are  little  liable  to 
bleed  per  se ;  but  if  submucous,  tliey  irritate  the  endometrium  and 
set  up  hemorrhagic  endometritis.  Cancer  and  sarcoma  not  only  cause 
hemorrhagic  endometritis,  but  themselves  rapidly  undergo  necrotic 
changes,  and  thus  become  the  source  of  hemorrhage.  Extra-uterine 
growths  may  induce  menorrhagia  by  the  pelvic  irritation  and  conse- 
quent congestion  to  which  they  give  rise. 

3.  Displacements. — Deviations  of  the  uterus  and  its  appendages, 
through  traction  on  the  pelvic  blood-vessels,  may  so  obstruct  the  cir- 
culation as  to  cause  venous  congestion  and  a  consequent  excessive 
menstrual  effort  to  lessen  the  quantity  of  blood  in  the  pelvis.  The 
complete  relief  from  menorrhagia  that  sometimes  follows  the  correc- 
tion of  a  prolapsed  or  flexed  uterus  by  means  of  artificial  support, 
and  the  prompt  return  of  excessive  menstruation  upon  withdrawal  of 

'  "Arteriosclerosis  of  the  Uterus."  Findley.  American  Journal  of  Obstetrics,  vol.  xliii.,  No. 
1, 1901. 


752  DISORDERS  OF  MENSTRUATION  AND  STERILITY. 

the  support,  are  satisfactory  proof  that  displacement  may  cause  uterine 
hemorrhage.  Further  information  on  this  subject  may  be  found  in 
Part  V.  on  Displacements. 

4.  Foreign  Bodies. — Tents  and  other  foreign  bodies  which  find 
their  way  into  the  uterus  either  from  therapeutic  or  criminal  motives 
may,  by  their  irritating  presence,  cause  excessive  flow.  An  embryo 
detached  in  the  course  of  abortion  is  a  familiar  example  of  foreign 
body  in  the  uterus. 

5.  Systemic  Disorders.^ — Any  general  disorder  that  will  embar- 
rass the  return  flow  of  blood  from  the  pelvic  viscera  will  cause  an 
increased  vascular  pressure  that  may  result  in  hemorrhage  from  the 
uterus.  Among  the  systemic  conditions  that  may  underlie  exces- 
sive menstruation  are:  hemorrhagic  diathesis,  scorbutus,  purpura, 
malaria,  lead-poisoning,  and  acute  infectious  diseases  such  as  scarlet 
fever,  diphtheria,  and  typhoid  fever.  Menorrhagia  associated  with 
such  causes  is  often  difficult  to  treat,  because,  as  Groom  says,  these 
causes  interact  in  such  a  way  as  to  form  a  vicious  circle — the  drain 
on  the  system  from  the  hemorrhage  tending  to  aggravate  the  systemic 
condition,  which  in  its  turn  leads  to  the  monorrhagia.  Chronic 
mental  depression,  hysteria,  sedentary  habits,  and  residence  in  high 
altitudes  or  the  tropics,  all,  in  greater  or  less  degree,  dispose  to  menor- 
rhagia.  In  some  cases  anaemia,  although  usually  a  cause  of  amenor- 
rhoea  or  scanty  menstruation,  may  cause  uterine  hemorrhage.  This  is 
explained  possibly  by  the  low  specific  gravity,  the  diminished  coagula- 
bility of  the  blood,  or  faulty  nutrition  of  the  vessels. 

6.  Visceral  Diseases. — Heart  diseases,  such  as  hypertrophy,  dila- 
tation, mitral  insufficiency,  or  stenosis,  as  well  as  cirrhotic  changes  in 
the  liver  or  kidney,  are  associated  usually  with  such  organic  change 
or  functional  disturbance  in  the  blood-vessels  as  to  cause  embarrass- 
ment of  circulation  and  hemorrhage  in  various  organs.  Under  one 
or  more  of  the  disorders  just  named,  the  uterus,  being  the  seat  of  a 
normal  periodic  hemorrhage,  and  being  therefore  predisposed  to 
hemorrhage,  may,  especially  if  there  be  disease  of  the  endometrium, 
readily  become  the  medium  of  exaggerated  menstruation. 

7.  Uterine  Moles. — Among  the  occasional  causes  of  uterine  hem- 
orrhage may  be  mentioned  uterine  moles.  There  are  two  varieties : 
1,  fleshy  mole;  2,  hydatiform  mole,  sometimes  called  Gystie  mole, 
and  sometimes  wrongly  called  uterine  hydatids. 

^  Fleshy  Mole. — The  so-called  fleshy  mole  is  associated  sometimes 
with  hemorrhage  from  the  uterus,  and  when  so  associated  gives  rise 
to  abnormal  signs  of  pregnancy.  It  may  be  recognized  upon  spon- 
taneous expulsion  or  removal. 

Hydatiform  mole  is  the  result  of  cystic  degeneration  of  the  chorionic 
villi.  It  gives  rise  to  pronounced  and  constant  or  almost  constant 
hemorrhage,  and  is  associated  with  rapid  increase  in  the  size  of  the 
uterus,  together  with  the  usual  signs  of  pregnancy.  The  diagnosis 
will  depend  upon  the  expulsion  of  a  part  or  all  of  the  vesicles. 
Although  hydatiform  mole  and  hydatids  (echinococcus)  resemble  one 
another  in  gross  appearance,   they   have   no  other    characteristic   in 

«  Croom :  System  of  Gynecology,  AUbutt  and  Playfair. 


UTERINE  HEMORRHAGE.  753 

common.     Uterine  hydatids  (echinococcus)  have  been   observed,  but 
they  are  of  very  rare  occurrence. 

When  the  causes  of  menorrhagia  are  so  obscure  that  they  cannot  be 
detected,  the  hemorrhage  has  been  termed  idiopathic.  The  use  of 
such  a  terra  explains  nothing.  It  is  better  to  say  outright  that  the 
symptom  is  of  unknown  origin. 

Diagnosis  of  Uterine  Hemorrhage. 

Before  deciding  what  constitutes  an  excessive  loss  of  blood,  it  is 
necessary  to  adopt  at  least  an  approximate  standard  of  the  normal 
amount.  As  stated  in  the  chapter  on  Scanty  Menstruation,  men- 
orrhagia is  a  relative  condition.  An  anaemic  woman  whose  blood 
is  scarcely  sufficient  to  meet  the  fixed  requirements  of  nutrition  can 
ill  afford  to  spare  what,  in  a  robust  state,  would  be  even  less  than 
normal ;  and  for  such  a  woman  amenorrhoea  may  be  a  means  of 
saving  much  needed  blood,  and  in  a  relative  sense,  therefore,  may  be 
considered  normal.  On  the  other  hand,  in  an  exceptional  case  of 
plethora,  eight  or  nine  days  of  free  menstruation  may  cause  no  ill- 
effect — may,  indeed,  be  beneficial,  and  therefore  normal.  We  may, 
however,  for  practical  purposes  arbitrarily  limit  the  normal  duration 
of  menstruation  to  six  days,  and  the  number  of  napkins  soiled  in  that 
time  to  about  fifteen. 

In  the  diagnosis  of  menorrhagia,  one  must  exclude  all  bleeding 
from  extra-uterine  sources,  such  as  the  bleeding  from  hemorrhagic 
vulvovaginitis,  from  traumatism  of  the  vulva  or  vagina,  and  from 
varicose  veins  of  the  vulva. 

The  mere  discovery  of  menorrhagia  is  only  the  recognition  of  a 
symptom.  The  practical  diagnosis  includes  as  well  the  discovery  of 
the  cause  or  causes  of  that  symptom.  Only  in  this  way  is  a  rational 
prognosis  or  effective  plan  of  treatment  made  possible.  The  causes 
that  produce  menorrhagia,  and  that  have  already  in  a  general  way 
been  outlined  in  preceding  paragraphs  of  this  chapter,  will  be  found 
discussed  more  fully  in  the  other  chapters  that  specially  treat  of 
them. 

The  diagnosis  of  menorrhagia  will  vary  according  to  the  age  of  the 
patient  somewhat  as  follows  : 

Uterine  Hemorrhage  of  Girls. — Inasmuch  as  the  menorrhagia  of 
girls  and  of  very  young  unmarried  women  is  in  a  very  large  propor- 
tion of  cases  due  to  general  systemic  conditions,  it  is  obvious  that 
uterine  examinations  in  such  cases  should  at  first  be  avoided.  If  the 
general  examination  has  failed  to  disclose  the  causative  lesion,  or 
general  treatment  has  failed  to  give  relief,  a  pelvic  examination  may 
be  the  only  means  of  diagnosis,  and  therefore  may  be  imperative.  It 
does  not,  however,  by  any  means  follow  that  a  minor  local  disturb- 
ance, even  though  coexistent  with  menorrhagia,  should  be  made  the 
occasion  of  local  treatment.  A  case  in  point  may  be  cited  from  the 
writer's  experience  in  which  there  were  protracted  menorrhagia  and 
increased  uterine  secretion,  both  promptly  disappearing  upon  correction 
of  a  lateral  curvature  in  the  lumbar  region  of  the  spine  by  means  of 


754  DISORDERS  OF'  MENSTRUATION  AND  STERILITY. 

a  plaster  jacket.  The  symptoms  complained  of  may  perhaps  have  been 
due  to  faulty  nutrition,  and  this  in  turn  may  have  been  perpetuated 
by  the  curvature ;  at  any  rate,  whatever  the  explanation,  the  relief 
was  complete.  The  author  has  observed  one  case  of  profuse  menstrua- 
tion and  intermenstrual  hemorrhage  in  a  young  girl  which  apparently 
was  due  to  chronic  appendicitis. 

Uterine  Hemorrhage  during"  the  Period  of  Maturity  is,  in  a 
majority  of  cases,  dependent  solely  or  partly  upon  local  pelvic 
disease,  such  as  infection,  displacements,  tumors,  and  products  of  con- 
ception. Very  commonly  the  local  disease  coexists  with  general 
disorders.  Such  cases  frequently  demand  local,  general,  or  operative 
treatment. 

Uterine  Hemorrhage  during  the  Menopause. — To  avoid  repeti- 
tion, the  reader  is  referred  to  a  partial  discussion  of  the  subject  in 
Chapter  I.  If  the  menopause  is  characterized  by  a  long-continued 
series  of  hemorrhages  or  by  constant  hemorrhage,  the  probability  is 
that  endometritis,  inflammation  of  the  uterine  appendages,  or  a  tumor 
exists,  and  retards  the  atrophic  process  and  consequent  normal  amenor- 
rhoea  which  at  this  time  should  take  place.  It  may  be  laid  down  as  a 
general  proposition,  moreover,  that  an  abnormal  menopause,  even 
though  not  hemorrhagic,  is  a  positive  indication  for  thorough  exam- 
ination, both  local  and  general,  with  a  view  to  accurate  and  adequate 
diagnosis.  This  indication  is  strengthened  by  the  frequent  develop- 
ment, during  this  critical  period,  of  malignant  disease  and  mental 
disorder. 

Treatment  of  Uterine  Hemorrhage. 

The  foregoing  paragraphs  on  etiology  and  diagnosis,  when  consid- 
ered in  their  relations  to  treatment,  should  lead  to  the  following  gen- 
eral statement,  to  which,  however,  numerous  exceptions  will  arise  : 

The  treatment  of  uterine  hemorrhage  in  girls  and  young  women  is 
often  that  of  a  systemic  cause ;  the  treatment  in  married  women  of 
the  childbearing  age  is  usually  that  of  endometritis,  benign  tumors, 
or  displacements ;  the  treatment  of  the  menorrhagia  of  spinsters  is 
commonly  that  of  benign  tumors  ;  and  of  women  between  the  ages  of 
forty  and  fifty  years,  often  that  of  malignant  growths  or  myomata; 
the  treatment  during  senility  is  often  that  of  malignant  disease. 

The  therapeutic  measures  most  frequently  employed  comprise : 

1.  Systemic  treatment. 

2.  Local  treatment. 

3.  Electrotherapeutics. 

4.  Surgical  operations. 

1.  Systemic  Treatment. — Rest  in  bed  during  the  most  excessive 
part  of  the  flow,  freedom  from  mental  disturbance,  bathing,  passive 
exercise,  the  use  of  nutritious,  non-irritating  food,  the  avoidance  of 
stimulants,  and  residence  in  a  temperate  or  cold  climate  at  or  near 
the  sea-level,  are  the  principal  hygienic  measures.  Drugs,  such  as 
stypticin,  salines,  ergot,  digitalis,  cinnamon,  nuclein,  and  hydrastis 
canadensis,  may  be  selected  according  to  special  indications.     When 


UTERINE  HEMORRHAGE.  755 

there  is  systemic  hemophilia  an  abundance  of  s^elatine  taken  with  the 
food  is  known  to  increase  the  coagulability  of  the  blood. 

2.  Local  Treatment. — The  hot-water  vaginal  douche  and  vaginal 
and  uterine  tamponade,  as  described  in  Chapters  IV.  and  XXVII., 
are  the  two  most  satisfactory  means  of  local  treatment.  The  latter, 
especially  as  a  temporary  measure,  if  })roperly  applied,  is  most  effec- 
tive. Intra-uterine  applications  of  adrenalin  have  been  recommended 
highly.  Intra-uterine  injections  of  strong  astringents,  such  as  con- 
centrated solutions  of  iodine  and  tincture  of  iron,  are  used  frequently, 
and  may  in  some  cases  be  promptly  effective ;  but  the  liability  of 
setting  up  painful  uterine  contractions  and  the  danger  of  invasion  of 
the  Fallopian  tubes  and  of  possible  pelvic  infection,  are  serious  objec- 
tions to  their  general  use. 

3.  Electrotherapeutics. — The  subject  of  electrotherapeutics  has 
been  mentioned  in  the  treatment  of  endometritis  and  myoma.  Chapters 
XVII.  and  XXVI.     The  value  of  it  has  been  much  overestimated. 

4.  Surgical  Operations. — The  operative  treatment  is  usually  not 
directly  that  of  the  mere  symptom,  hemorrhage  ;  but  rather  of  such 
diseases  as  endometritis,  metritis,  myoma,  cancer,  and  sarcoma.  The 
surgery  of  these  diseases  may  be  found  discussed  in  other  parts  of 
the  book. 


CHAPTEE    LIII. 

DYSMENORRHCEA    AND    PERIODIC    INTERMENSTRUAL 

PAIN. 

DYSMENORRHCEA. 

Definition  and  Classification. 

Dysmexorrhcea  is  painful  menstruation.  This  definition  does 
not  include  the  slight  heaviness  in  the  loins,  the  general  malaise,  the 
vague  sense  of  discomfort,  and  the  irritability  that  go  to  make  up 
"the  unwell  feeling"  of  healthy  women  during  the  menstrual  week. 
The  slight  "  unwell  symptoms  "  so  called,  although  sometimes  absent 
in  normal  cases,  are  not  evidences  of  disease,  and  may  therefore  be 
disregarded. 

The  numerous  attempts  to  classify  dysmenorrhoea  have  led  to  the 
use  of  a  complicated  and  abundant  nomenclature,  of  which  each  term 
is  taken  to  designate  a  particular  variety  of  painful  menstruation. 
Dysmenorrhoea  accordingly  has  been  characterized  variously  as  tubal, 
ovarian,  membranous,  inflammatory,  congestive,  neuralgic,  spasmodic, 
intermenstrual,  mechanical,  or  constitutional.  Such  designations, 
although  useful  for  purposes  of  description,  are,  when  considered 
from  the  standpoint  of  classification,  wholly  misleading.  The  morbid 
conditions  associated  with  painful  menstruation  are  to  a  considerable 
extent  common  to  most  of  the  so-called  varieties.  For  example, 
dysmenorrhoea  of  inflammatory  causation  might  originate  in  the 
ovary,  tube,  or  uterus.  It  necessarily  would  be  associated  vnth  con- 
gestion, it  might  take  place  in  the  intermenstrual  period,  or  might 
be  aggravated  by  causes  of  a  mechanical  or  constitutional  nature. 
Almost  any  one  of  the  above  names,  therefore,  might  with  equal 
propriety  be  applied  to  designate  this  so-called  variety.  The  other 
terms  proposed  to  designate  special  varieties  are  subject  to  similar 
criticism.  Furthermore,  the  difficulty — not  to  say  impossibility — of 
making  in  the  present  state  of  our  knowledge  a  scientific  or  practical 
classification  of  dysmenorrhoea  will  become  even  more  apparent  from 
what  follows. 

Clinical  History  and  Diagnosis  of  Dysmenorrhoea. 

Degrees  of  Pain. — Pain  associated  with  menstruation  varies  in 

the  widest  limits  from  the  general  malaise  of  the  "unwell  week"  to 
the  most  intense  agony.  In  many  cases  the  pain  is  associated  with 
definite  lesions,  and  disappears  upon  the  cure  of  those  lesions.  In 
other  cases  the  suffering  is  wholly  out  of  proportion  to  the  associated 
disease — that  is,  a  woman  presenting  the  most  exaggerated  evidence 
756 


D  YSMENOR  RHCEA .  757 

of  pain  may  upon  careful  examination  disclose  little  or  no  disease  to 
account  for  it ;  on  the  other  hand,  extensive  disease  may  exist  and 
yet  give  rise  to  little  or  no  dysmenorrhoea. 

Character  of  Pain. — It  is  usual  in  the  taking  of  histories  of  gyne- 
cological practice  to  note  the  character  of  the  pains,  and  to  designate 
them  by  such  words  as  distinct,  sharp,  dull,  heavy,  radiating,  dragging, 
bearing-down,  and  labor-like.  The  maximum  pain  may  be  in  the 
back,  loins,  or  pelvis ;  it  may  be  constant,  intermittent,  or  remittent ; 
it  may  come  on  or  be  most  intense  before  or  during  menstruation ;  it 
may  cease  or  may  increase  with  the  establishment  of  the  flow  ;  it  may 
continue  only  during  the  first  day  or  two,  or  with  varying  degrees  of 
intensity  may  outlast  the  period. 

Unfortunately,  the  conditions  that  determine  the  variation  in  the 
degree  and  character  of  the  pain  are,  for  the  most  part,  not  very  defi- 
nitely known.  So  far,  however,  as  the  conditions  are  known  and  have 
a  practical  clinical  value  they  will  be  considered  later. 

The  following  four-fold  statement  relative  to  the  phenomena  of 
normal  menstruation,  if  read  in  connection  with  Chapter  I.,  will  per- 
haps help  the  student  to  understand  the  variations  of  dysmenorrhoea  :^ 

1.  There  is,  in  normal  menstruation,  a  general  premenstrual  and 
menstrual  congestion  of  the  pelvic  organs. 

2.  Ovulation  is  associated  usually  with  menstruation,  but  is  not  an 
essential  factor  of  it. 

3.  There  are  slight  premenstrual  enlargement  and  softening  of  the 
uterus  associated  with  congestion  and  swelling  of  the  mucosa,  reach- 
ing their  maximum,  according  to  Herman,  on  the  fourth  day  of  the 
flow,  and  continuing  for  a  short  time  after  the  bleeding  stops. 

4.  The  menstrual  fluid  is  composed  chiefly  of  blood,  but  with 
admixture  of  cast-off  epithelial  cells  and  lymph-corpuscles. 

Painful  menstruation,  in  exceptional  instances,  may  exist  unasso- 
ciated  with  any  demonstrable  lesion.  In  the  vast  majority  of  cases, 
however,  careful  examination  and  close  analysis  will  disclose  either 
a  local  or  a  systemic  cause,  or  both  combined. 

Associated  Lesions. — In  the  absence  of  a  scientific  and  adequate 
classification  one  may  consider  dysmenorrhoea  in  its  relations  with 
certain  associated  lesions ;  these  lesions  are  designated  under  two 
heads,  as  follows  : 

A.  Local  diseases,  usually  situated  in  the  pelvis. 

B.  General  diseases,  usually  faults  of  nutrition. 

A.   Dysmenorehcea  associated  w^th  Local  Diseases. 

The  local  diseases  commonly  associated  with  dysmenorrhoea  are ; 

1.  Inflammation. 

2.  Tumors. 

3.  Obstruction. 

4.  Malformations. 

1.  Inflammation. — Chronic  Endometritis. — The  most  pronounced 
type  of  dysmenorrhoea  dependent  upon  inflammation  is  described  in 

•  Webster.    Diseases  of  Women. 
46 


758  DISORDERS  OF  MENSTRUATION  AND  STERILITY. 

Chapter  XVI.,  and  is  known  as  membranous  dysmenorrhoea ;  it  is 
due  to  an  exfoliative  endometritis,  which  results  in  the  casting  out, 
either  complete  or  in  shreds,  of  an  entire  membranous  layer  from  the 
uterine  mucosa.  This  exfoliation  is  consequent  upon  a  process  the 
nature  of  which  is  unknown,  which  so  modifies  the  superficial  layer 
of  the  endometrium  that  the  blood,  not  being  able  to  pass  through  it, 
accumulates  at  some  point  behind  and  forcibly  strips  up  a  portion 
of  it.  There  is  then  an  effort  of  the  uterus  to  expel  the  partially 
detached  portion  ;  and  as  this  is  forced  toward  the  external  os  it  strips 
off"  and  drags  after  it  the  remaining  undetached  portion.  The  strip- 
ping off  and  expulsion  through  the  narrow  cervical  canal  of  the  entire 
layer  are  associated  with  very  strong  intermittent  uterine  contractions 
and  consequent  spasmodic  pain  of  the  most  intense  character.  If  the 
membrane  is  detached  and  cast  off  in  shreds,  the  pain  will  be  less 
severe ;  if  it  is  cast  off  in  minute  particles,  the  pain  may  be  very 
slight.  Membranous  dysmenorrhoea,  therefore,  for  different  individ- 
uals and  at  different  times  for  the  same  individual  may,  according  to 
the  size  of  the  exfoliated  masses,  be  very  slight  or  most  intense. 

Projections  into  the  endometrium  of  granulation-tissue,  the  product 
of  chronic  endometritis,  may  stimulate  the  swollen  irritable  uterus  to 
spasmodic  contractions  similar  to  those  of  membranous  dysmenorrhoea, 
though  usually  less  severe.     See  Chapter  XVI. 

Chronic  Metritis. — Dysmenorrhoea  when  associated  with  chronic 
metritis  may  be  attributed  to  the  presence  of  an  abnormal  amount  of 
fibrous  tissue ;  this  tissue  is  so  dense  and  unyielding  that  it  prevents 
the  normal  premenstrual  softening  of  the  uterus  and  the  widening  of 
the  uterine  canal,  and  in  this  way,  especially  when  the  organ  is  con- 
gested, may  exert  painful  pressure  on  the  uterine  nerves.  Metritis 
does  not  necessarily  cause  dysmenorrhoea.  The  symptom  may  result 
from  the  complications  of  metritis,  such  as  displacement,  fixation,  or 
stenosis  of  the  uterus,  inflammation  of  the  uterine  appendages,  chronic 
cellulitis,  chronic  peritonitis,  or  some  neurosis. 

Chronic  Salpingitis. — No  satisfactory  explanation  has  been  given 
of  the  severe  dysmenorrhoea  that  sometimes  accompanies  salpingitis. 
Cases  in  which  the  tube  is  distended  moderately  with  pus  are  usually 
more  painful  than  those  in  which  there  is  great  distention.  Moreover, 
severe  salpingitis  may  exist,  and  yet  give  rise  to  no  dysmenorrhoea. 
For  further  information  on  the  subject  the  reader  is  referred  to 
Chapters  XXI.  and  XXII. 

Chronic  Ovaritis  is  almost  inseparable  from  inflammation  of  other 
pelvic  organs.  Its  influence  therefore  as  a  cause  of  dysmenorrhoea 
cannot  be  estimated  accurately.  Painful  menstruation  associated  with 
ovaritis  is  characterized  often  by  a  period  of  premenstrual  suffering 
variable  in  duration,  by  rather  pronounced  nervous  symptoms,  and 
by  mammary  tenderness.  Ovarian  pain  is  especially  apt  to  radiate 
to  the  thighs  and  nates.  Pain  referred  to  the  ovaries  is  common, 
and  often  exists  in  the  absence  of  a  demonstrable  lesion  in  the  ovaries. 
Removal  of  the  ovaries  under  such  conditions  seldom  gives  permanent 
relief. 

2.  Tumors. — The  tumors  most  frequently  associated  with   dys- 


DYSMENOBRHCEA.  759 

menorrhoea  are  uterine  myomata  of  the  intramural,  submucous,  or 
intra-uterine  variety.  These  tumors  may,  especially  during  the 
period  of  menstrual  congestion,  cause  pain  in  the  following  ways  : 

1.  An  intra-uterine  or  intramural  tumor  may  stimulate  the  uterus 
to  attempt  its  expulsion  by  painful  uterine  contraction. 

2.  A  tumor  may  by  its  weight  produce  displacement  of  the  uterus 
and  consequent  painful  menstruation. 

3.  A  tumor,  if  it  fills  the  pelvis,  may  produce  pressure-symptoms ; 
and  these  symptoms  may,  owing  to  the  menstrual  congestion^  be 
aggravated  during  the  catamenia. 

Displacements  of  the  uterus  as  associated  factors  in  dysmenorrhoea 
are  considered  further  in  Part  V.  In  this  connection  the  reader's 
attention  is  directed  specially  to  the  subject  of  anteflexion  as  laid 
down  in  Chapter  XLVIII. 

3.  Obstruction. — Stenosis  within  the  cervical  canal,  and  conse- 
quent obstruction  to  the  outflow  of  blood,  have  held  a  large  place  in 
the  controversial  literature  of  dysmenorrhoea.  The  claimants  for  the 
mechanical  theory,  on  the  one  hand,  sometimes  have  attributed  all, 
or  nearly  all,  painful  menstruation  to  narrowing  of  the  uterine  canal ; 
while  their  opponents  not  infrequently  have  denied  altogether  to  this 
cause  any  considerable  place  in  the  causation  of  dysmenorrhoea.  It 
may  be  sufficient,  without  going  over  the  arguments  for  and  against 
the  mechanical  theory  of  dysmenorrhoea,  to  say  that  contraction  of 
the  cervical  canal  has  been  properly  almost  excluded  as  a  direct 
mechanical  cause  of  dysmenorrhoea.  The  following  paragraph  w'ill 
show,  however,  that  this  exclusion  does  not  by  any  means  dispose  of 
mechanical  obstruction  as  a  frequent  indirect  cause  of  painful  men- 
struation. 

Two  forms  of  obstruction  may  be  due  to  anteflexion.  One  is 
obstruction  in  the  uterine  canal,  due  to  collapse  of  the  uterine  canal 
at  the  point  of  bending ;  the  other  is  obstruction  in  the  blood-vessels, 
due  to  collapse  of  the  walls  of  the  vessels  also  at  the  point  of  bend- 
ing. The  obstruction  which  causes  the  dysmenorrhoea  is  commonly 
in  the  blood-vessels,  not  so  commonly  in  the  uterine  canal. 

Some  authorities  deny  that  dysmenorrhoea  when  associated  with 
flexion  is  in  any  sense  due  to  obstruction  either  in  the  uterine  canal 
or  in  the  vessels,  and  attribute  the  pain  wholly  to  the  associated 
uterine  or  extra-uterine  inflammation.  It  is  true  that  inflammation 
in  a  sense  causes  the  pain  ;  but  it  is  also  true  that  it  causes  the  flexure, 
and  that  the  flexure,  once  formed,  tends  to  keep  up  the  inflammation. 
The  two  together  constitute  what  has  been  called  a  vicious  circle ;  the 
former  producing  the  latter,  and  the  latter  reacting  to  aggravate  and 
perpetuate  the  former.  A  more  full  statement  of  the  two  forms  of 
obstruction  may  be  found  in  Chapter  XLVIII. 

4.  Malformations. — Malformations  of  the  pelvic  organs  may  be 
associated  with  dysmenorrhoea  in  the  following  way  :  there  may  be 
atresia  somewhere  in  the  genital  tract,  with  consequent  retention  of 
menstrual  fluid,  so  that  during  successive  periods  the  blood  accumu- 
lates with  steadily  increasing  and  painful  distention. 


760  DISORDERS  OF  MENSTRUATION  AND  STERILITY. 

B,  Dysmenorehcea  associated  with  General  Diseases. 

The  strong  surgical  bias  in  gynecological  practice,  emphasized  by 
the  remarkable  results  that  have  been  obtained  by  operative  and 
mechanical  measures,  and  by  the  relative  safety  of  such  measures 
when  aseptically  employed,  has  led,  during  the  last  generation,  to 
an  undue  estimate  of  the  value  of  surgical  procedures,  and  to  a  cor- 
responding neglect  of  general  therapeutic  requirements.  Accordingly, 
there  has  been  during  the  past  thirty  years  a  strong  movement  along 
surgical  and  mechanical  lines,  and  a  corresponding  disposition  to  dis- 
regard the  claims  of  internal  medicine.  On  the  other  hand,  to  ignore 
extrapelvic  causes  of  pelvic  pain  or  to  disregard  pelvic  causes  of  sys- 
temic disturbances  would  be  manifestly  absurd.  In  either  case  most 
embarrassing  blunders  in  diagnosis  and  treatment  necessarily  would 
follow. 

Many  constitutional  and  systemic  conditions  predispose  to  painful 
menstruation  ;  they  may  be  associated  with  dysmenorrhcea  with  or 
without  demonstrable  local  lesions.  In  some  cases  in  which  local 
disease  is  not  present,  or,  if  present,  is  not  sufficient  to  account  for 
the  menstrual  pain,  the  dysmenorrhcea  must  be  attributed  chiefly 
or  wholly  to  general  causes.  Among  the  general  disorders  often 
associated  with  dysmenorrhcea  are  rheumatism,  gout,  anaemia,  chlo- 
rosis, malaria,  neurasthenia,  and  hysteria.  What  Goodell  aptly  called 
the  intangible,  imponderable,  invisible  pelvic  pains  of  neurotic  women 
are  especially  liable  to  increase  during  menstruation. 

In  one  pronounced  class  of  cases  the  reproductive  organs  may, 
from  lack  of  proper  innervation  and  nutrition,  have  failed  to  mature 
at  the  age  of  puberty,  and  therefore  may  perform  the  menstrual  func- 
tion imperfectly ;  the  defect  declares  itself  not  infrequently  in  the 
form  of  an  intensely  painful  effiart  to  menstruate — that  is,  a  painful 
molimen  with  little  or  no  flow.  The  lack  of  innervation  and  nutri- 
tion in  such  cases  is  not  often  confined  to  the  pelvic  organs  ;  it  is 
usually  systemic.  Dysmenorrhcea  of  this  kind,  therefore,  has  both  a 
systemic  and  a  local  source. 

Among  the  neuroses  most  frequently  associated  with  dysmenor- 
rhcea are  neurasthenia  and  hysteria ;  the  one,  characterized  by  exces- 
sive hypersesthesia  and  involving  motor  weakness ;  the  other,  charac- 
terized by  loss  of  power  and  codrdination  over  automatic  movements 
and  by  an  excessive  responsiveness  to  suggestion.  Either  of  these 
neuroses  may  coexist  with  dysmenorrhcea  in  cases  that  present  no 
local  disease,  or  local  disease  so  slight  that  in  an  otherwise  normal 
woman  it  would  have  little  or  no  recognition. 


Treatment  of  Dysmenorrhcea. 

There  are  two  possible  errors  that  may  be  made  in  connection 
with  treatment.  One  is  that  a  distinct  nervous  or  other  general  dis- 
order closely  related  to  the  causation  of  the  pain  may  be  overlooked 
or  neglected  ;  the  other  is  that  exaggerated  importance  may  be  given 


PERIODIC  INTERMENSTRUAL  PAIN.  761 

to  some  insignificant  local  lesion,  that  this  exaggeration  may  result  in 
an  error  of  judgment,  and  that  much  local  treatment  of  what  is  known 
as  the  tinkering  kind  may  be  ad(^pted  or  that  unnecessary  operations 
may  be  performed.  Of  course,  the  opposite  mistake  may  be  made — 
that  is,  unnecessary  general  treatment  may  be  employed  to  the  exclu- 
sion of  necessary  local  or  surgical  treatment.'  Norman  Kerr,  of  Chi- 
cago, reports  cases  of  dysmenorrhoea  associated  with  ovaritis  in  wiiich 
relief  was  obtained  by  resection  of  the  uterine  vessels  and  nerves  as 
they  pass  through  the  infundibulopelvic  ligament.^ 

The  treatment  of  dysmenorrhoea,  like  the  cause,  is  either  local  or 
general,  or  both. 

Local  Treatment. — The  term  local  treatment  here  used  is  extended 
beyond  the  usual  meaning,  and  includes  both  non-surgical  and  surgical 
measures.  These  measures  are  described  in  various  chapters  of  this 
book. 

General  Treatment. — The  general  treatment  is  that  of  the  consti- 
tutional and  systemic  conditions  already  outlined  among  the  possible 
causes  of  painful  menstruation.  The  subject  is  almost  coextensive 
with  the  whole  field  of  general  internal  medicine,  and  cannot  there- 
fore adequately  be  discussed  within  the  limits  of  a  gynecological 
treatise. 

PERIODIC  INTERMENSTRUAL  PAIN. 

(German,  Mittelschmerz.) 

Periodic  pain,  resembling  the  pain  of  obstructive  dysmenorrhoea, 
recurring  regularly  with  each  intermenstrual  period,  and  continuing 
for  a  definite  time,  is  a  condition  that  often  defies  analysis  and  treat- 
ment. All  explanations  of  this  phenomenon  are  more  or  less  specu- 
lative.    The  three  most  rational  theories  are  that  the  pain  is  caused  by : 

1.  Sclerosis  and  contraction  of  the  ovary. 

2.  Salpingitis  profluens. 

3.  Obstruction  in  the  uterine  canal. 

1.  Sclerosis  and  Contraction  of  the  Ovary. — Hyperplastic 
thickening  and  toughening  of  the  superficial  structure  covering  the 
Graafian  follicles  may  offer  such  resistance  to  the  bursting  of  mature 
follicles  as  to  cause  pain.  It  is  urged  that  there  is  no  periodicity  in 
the  maturing  and  bursting  of  the  follicles,  and  that  the  sclerosis  there- 
fore, while  it  might  account  for  the  pain,  could  not  account  for  the 
periodicity  of  it ;  a  speculative  reply  to  this  objection  would  be  that 
ovulation  from  some  unexplained  cause,  perhaps  reversion  to  a  former 
type,  may  in  rare  instances  preserve  a  regular  periodicity,  and  that  in 
such  exceptional  cases  sclerotic  toughening  would  account  for  the 
periodic  intermenstrual  pain. 

The  writer  once  removed  a  sclerotic  right  ovary  and  tube,  with 
entire  relief  to  the  patient,  from  a  most  excruciating  Mittelschmerz  that 
had  for  a  long  time  resisted  all  other  treatment.  The  relief,  how- 
ever, continued  only  through  the  two  periods  immediately  following 
the  operation.     The  pain  at  the  time  of  the  third  and  fourth  periods 

1  Adaptation  from  W.  S.  Playfair,  in  a  System  of  Gynecology. 
sUlinois  Medical  Journal,  December,  1903. 


762  DISORDERS   OF  MENSTRUATION  AND  STERILITY. 

recurred,  and  was  nearly  as  severe  as  before;  but  since   the  fourth 
period  there  has  been  partial  relief. 

2.  Salpingitis  Profluens. — In  numerous  instances  intermenstrual 
pain  of  long  standing  has  disappeared  permanently  upon  the  removal 
of  leaky  Fallopian  tubes — hydrosalpinx  or  pyosalpinx.  The  perio- 
dicity of  the  pain  in  cases  of  this  class  is  explained  by  the  assertion 
that  a  certain  definite  number  of  days  after  each  menstruation  ^vould 
be  required  for  the  tube  to  fill  with  secretions,  and  that  being  filled  it 
discharges  its  contents  with  regularly  recurring  pains.  There  is  no 
evidence  in  these  cases  to  show  absence  of  cirrhosis  of  the  ovary, 
hence  the  cause  of  the  pain  may  have  been  ovarian  and  not  tubal. 

3.  There  may  be  obstruction  in  the  uterine  canal  from  stenosis  or 
flexure,  and  consequent  periodic  accumulations  of  uterine  secretions, 
which  are  regularly  expelled  by  labor  pains. 


CHAPTER   LIV. 

STERILITY. 

Definition  of  Sterility. 

Excluding  the  physiological  sterility  of  infancy  and  senility,  one 
may  define  sterility  as  the  inability  of  the  individual  to  produce 
offspring.  In  a  broad  sense,  a  woman  is  sterile  who  cannot  become 
pregnant,  or,  if  pregnant,  cannot  produce  a  viable  child.  A  man  is 
sterile  who  cannot  produce  semen  that  will  fertilize  an  ovum.  In  a 
narrow  sense,  a  woman  who  can  conceive  and  imbed  the  ovum  in  the 
endometrium  should  not,  if  the  ovum  then  dies  and  is  cast  off,  be 
classed  as  sterile.  The  condition,  strictly  speaking,  would  be  not  one 
of  sterility,  but  of  abortion.  From  the  clinical  standpoint,  however, 
such  early  abortion  is  not  easily  separable  from  sterility,  for  habitual 
abortion  may  occur  very  early  in  pregnancy — so  early  that  the  preg- 
nancy could  not  have  been  recognized.  Sterility  in  the  male,  except 
as  it  may  have  a  gynecological  significance  in  diagnosis  or  prognosis, 
will  not  be  discussed. 

Statistics  of  Sterility. 

Pathological  sterility,  as  distinguished  from  the  physiological 
sterility  of  infancy  and  senility,  is  confined  properly  to  the  years 
between  the  end  of  puberty  and  the  beginning  of  the  menopause — 
that  is,  to  the  period  of  maturity;  in  the  majority  of  cases  the  limits 
are  even  more  confined,  for  the  capacity  to  bear  children  is  seldom 
fully  developed  until  three  or  four  years  after  puberty,  and  it  gener- 
ally ceases  some  years  before  the  menopause.  Failure  to  bear  children 
therefore  in  the  early  years  of  maturity  or  in  the  late  years  of  the 
menopause,  even  though  it  might  indicate  lateness  in  the  development 
of  sexual  vigor  or  premature  decadence,  should  not  be  considered 
pathological,  and  for  this  reason  it  should  not  enter  into  the  statistics. 

It  is  said  that  10  or  12  per  cent,  of  all  marriages  are  sterile;  this, 
however,  is  not  an  index  to  the  frequency  of  female  sterility.  One 
must  also  reckon  with  the  fact  of  male  sterility.  The  pro})ortion  of 
cases  in  which  the  fault  is  in  the  male  has  never  been  the  subject  of 
thorough  investigation,  but  the  estimates  range  from  7  to  40  per  cent. 
The  percentage  is  undoubtedly  very  large,  and  has  added  greatly  to 
the  popular  estimate  of  female  sterility. 

Classification  of  Sterility. 

The  varieties  of  sterility,  according  to  the  causes  or  associated  con- 
ditions, have  been  designated  as  follows : 

1.  Complete  or  absolute  sterility. 

2.  Incomplete  or  contingent  sterility. 

763 


764  DISORDERS  OF  MENSTRUATION  AND  STERILITY. 

Some  authors  have  made  a  further  classification  of  congenital  and 
acquired  sterility;  these  varieties,  however,  are  only  subdivisions  of 
complete  and  contingent  sterility,  and  should  therefore  be  considered 
with  them. 

1.  Absolute  or  Complete  Sterility. — Sterility  is  absolute  when 
due  to  congenital  defects,  or  disease,  or  surgical  operations  that  render 
the  generative  organs  permanently  incapable  of  performing  their 
reproductive  functions.  The  organs  may  be  congenitally  defective  or 
absent,  or  may  be  impotent  from  disease,  or  may  have  been  removed 
by  surgery. 

2.  Relative  or  Partial  Sterility. — Sterility  is  relative  or  partial 
when,  on  account  of  some  defect  in  development  or  nutrition,  the 
functions  of  the  rejjroductive  organs  are  performed  inadequately.  The 
condition  may  be  only  temporary,  and  may  disappear  upon  improve- 
ment of  the  general  health  or  upon  removal  of  some  obstruction 
or  disease  in  the  genital  tract.  To  this  class  belong  cases  of 
pregnancy  occurring  after  years  of  sterile  marriage.  Some  observers 
designate  as  relative  only  that  variety  in  which,  on  account  of 
sexual  or  other  defects,  such  as  marital  or  mental  incompatibility,  a 
man  and  woman  are  unable  to  act  together  in  reproduction.  In  such 
cases  each  may  become  fruitful  immediately  after  a  second  marriage. 
The  question  then  would  be,  not  whether  the  individuals  are  posi- 
tively sterile,  but  rather,  what  is  the  explanation  of  the  sterile  union 
between  them.  Investigation  would  show  usually  that  the  failure 
was  due  rather  to  anatomical  or  physiological  defects  than  to  mere 
incompatibility.  Moreover,  the  ovum  of  a  sexually  defective  woman, 
although  not  impregnable  by  a  defective  man,  might,  when  brought 
in  contact  with  the  semen  of  a  normal  man,  readily  become  fertilized ; 
and  vice  versa,  the  semen  of  a  defective  man  might  fertilize  the  ovum 
of  a  normal  woman. 

Etiology  of  Sterility. 

A  knowledge  of  the  meclianism  of  conception  is  essential  to  an 
appreciation  of  the  causes  of  sterility.  A  large  portion  of  the  cortical 
substance  of  the  ovary  is  occupied  by  Graafian  follicles  in  all  periods 
of  growth ;  each  follicle  contains  a  fluid,  called  liquor  folliculi,  and 
the  ovum.  As  the  follicle  and  its  contained  ovum  mature  the 
former  gradually  becomes  distended  with  the  fluid,  appears  beneath 
the  surface,  ruptures,  and  discharges  its  contents.  The  ovum  is 
now  washed  out  into  the  pelvic  cavity,  and  under  normal  condi- 
tions reaches  the  Fallopian  tube  and  passes  along  the  tube  toward 
the  uterus.  If  at  this  time,  under  normal  conditions,  coitus  takes 
place,  and  seminal  fluid  containing  virile  spermatozoa  is  deposited  in 
the  upper  part  of  the  vagina,  the  spermatozoa,  of  their  own  power 
of  movement,  enter  the  endometrium  and  work  their  way  upward 
along  the  genital  tract  toward  the  descending  ovum.  The  exact 
meeting-place  of  the  two  organisms  is  not  known.  There  is  strong 
reason  to  infer  that  it  is  in  the  Fallopian  tube,  perhaps  at  the  abdom- 
inal end,  and  that  the  persistent  and  virile  spermatozoa  may  consume 


STERILITY.  IQrj 

several  days  in  traversing  the  long  distance  ;  they  have  been  observed 
at  the  abdominal  end  of  the  tube  as  late  as  live  weeks  after  the  last 
sexual  intercourse. 

There  are  two  necessary  conditions  fur  normal  conception  :  one, 
that  the  ovum  as  it  passes  down  the  genital  tract  shall  meet  the  sper- 
matozoa, and  by  them  become  fertilized  ;  the  other,  that  the  fertilized 
ovum  shall  find  in  the  endometrium  a  place  favorable  to  further 
development,  and  there  become  imbedded.  If  by  reason  of  anv  defect, 
general  or  local,  either  one  of  these  conditions  be  absent,  conception  is 
impossible.  The  ovum,  failing  to  reach  the  tube,  may  be  destroyed 
in  the  peritoneal  cavity ;  or,  having  reached  it,  may  pass  down  the 
genital  tract  and  fail  to  be  fertilized.  The  spermatozoa  may  not  be 
sufficiently  virile  to  find  their  way  upward  from  the  vagina  ;  or,  if 
they  reach  the  ovum,  they  may  not  be  able  to  fertilize  it.  The  two 
organisms  may  succumb  to  hostile  en\Tronment  or  to  some  anatomical 
defect.  As  indicated  in  the  foregoing,  a  sterile  marriage  may  result 
from  : 

1.  Absence  of  virile  spermatozoa. 

2.  Faulty  general  nutrition  in  the  woman. 

3.  Defective  reproductive  organs  in  the  woman. 

4.  Intermediate  causes. 


1.  The  Absence  of  Yieile  Spermatozoa. 

Old  age,  wasting  diseases,  congenital  defects,  and  venereal  diseases 
(especially  gonorrhoea)  may  incapacitate  the  man  to  produce  virile 
spermatozoa  or  may  destroy  entirely  the  procreative  power.  Many  a 
woman  has  sutfered  useless — not  to  say  injurious — treatment  for  sup- 
posed sterility  when  the  fault  was  entirely  with  the  husband.  An 
examination  of  the  husband's  reproductive  organs,  including  micro- 
scopical examination  of  the  semen,  may  disclose  orchitis,  stricture  of 
the  urethra,  hypospadias,  or  some  other  defect  that  may  account  ade- 
quately for  the  sterile  marriage.  A  careful  inquiry  should  be  made 
also  into  the  man's  general  cnrndition.  Tuberculosis  is  a  not  infrequent 
cause  of  sterility. 

2.  Faulty  General  Nuteitiox  ln'  the  Womax. 

Chronic  wasting  diseases  and  such  nutritional  disturbances  as 
chlorosis  and  ansemia,  and,  above  all,  the  accumidation  of  fat,  espe- 
cially the  peculiar  adiposity  of  anaemic  women,  due  to  faulty  metabol- 
ism, but  giving  the  false  appearance  of  plethora,  may  lead  to  sterility. 
Enteric  fever,  scarlatina,  cholera,  variola,  diabetes,  and  nephritis  are 
among  the  diseases  frequently  associated  with  sterility.  Premature 
menopause — that  is,  permanent  atrophy  of  the  reproductive  organs 
and  consequent  sterility — may  result  from  acute  infectious  disease. 
See  Non-puerperal  Atrophy,  Chapter  XVIII. 


766  DISORDERS  OF  MENSTRUATION  AND  STERILITY. 

3.  Defective  Reproductive  Organs  in  the  Woman. 

Defects  in  the  reproductive  organs,  both  congenital  and  acquired, 
according  to  their  nature,  may  give  rise  to  the  two  varieties  of  sterility 
designated  as  complete  and  incomplete. 

Congenital  Defects  in  the  Reproductive  Organs  causing  Complete   or 

Absolute  Sterility. 

1.  Absence  of  the  ovaries.  Fallopian  tubes,  or  uterus. 

2.  Rudimentary  ovaries,  Fallopian  tubes,  or  uterus. 

3.  Inoperable  atresia  in  the  genital  tract. 


Congenital  Defects  in    the    Reproductive  Organs    causing    Incomplete 
or   Contingent  Sterility. 

1.  Immaturity  or  innutrition  of  the  ovaries,  Fallopian  tubes,  or 
uterus. 

2.  Stenosis  or  atresia  in  the  genital  tract,  as  in  the  cervix  uteri, 
vagina,  or  vulva;  infantile  vulva;  abnormal  backward  location  of 
the  vulva. 

3.  Opening  of  the  vagina  into  the  bladder  or  rectum,  or  double 
vagina,  preventing  coition. 

4.  Displacements,  especially  flexures. 

5.  Elongation,  shortening,  or  conical  shape,  and  other  irregular 
developments    of    the   cervix    uteri. 

6.  Lengthening  of  one  lip  of  the  cervix  uteri,  so  as  to  form  a 
flap  over  the  os  uteri  externum. 

7.  Imperforate  hymen  or  cribriform  hymen,  transverse  vaginal 
septum. 

8.  Excessive  convolutions  or  increased  length  of  the  Fallopian 
tubes. 

9.  Double  uterus. 
10.  Gynandry. 

Discussion  of  Cong-enital  Causes.— For  a  more  extended 
description  of  congenital  defects  the  student  is  referred  to  Chapters 
XXXyil.  and  XXXVIIL,  on  Congenital  Malformations  and 
Gynatresia. 

A  rudimentary  condition  or  absence  of  the  ovary  may  coexist  with 
a  well-developed  uterus,  and  vice  versa  ;  either  combination  is  a  cause 
of  complete  sterility.  Absence  of  one  ovary,  if  the  other  is  normal  or 
approximately  normal,  is  not  necessarily  a  cause  of  sterility. 

Septate  or  double  vagina,  with  the  septum  so  disposed  as  to  divide 
the  vagina  into  unequal  parts,  may  permit  impregnation  if  the  larger 
part  is  capable  of  coition.  The  smaller  part  may  serve  only  for  men- 
struation. One  side  of  a  double  uterus  adequately  developed  may 
receive  the  impregnated  ovum  and  carry  it  to  maturity. 

Absence  or  impermeability  of  both  JFallopian  tubes,  unless  they  can 
be  opened  surgically,  causes  complete  or  absolute  sterility  ;  this  defect, 


STERILITY.  767 

however,  is  associated  usually  with  absent  or  rudimentary  uterus. 
Unicorn  uterus  permits  normal  pregnancy,  uterogestation,  and  partu- 
rition. Immaturity  and  innutrition  of  the  ovaries,  rendering  them 
incapable  of  producing  mature  ova,  are  associated  generally  with  some 
defect  in  the  general  systemic  development.  Rare  instances  have  been 
reported  in  which  the  reproductive  organs,  seemingly  undeveloped  at 
the  age  of  puberty,  have  later  developed  and  become  fruitful. 

Acquired  Defects  in  the  Reproductive    Organs    causing    Complete    or 

Absolide  Sterility. 

1.  Surgical  removal  of  the  uterus,  Fallopian  tubes,  or  ovaries. 

2.  Permanent  atrophy  of  the  uterus  or  ovaries. 

3.  Permanent  and  incurable  occlusion  of  the  Fallopian  tubes  or 
uterus. 

4.  Complete  destruction  from  disease  of  the  functionating  part 
(cortical  substance)  of  the  ovary  and  microcystic  degeneration  of 
the  ovary. 

Acquired  Defects  in  the  Reproductive   Organs  causing    Inconipjlete  or 

Contingent  Sterility. 

The  acquired  defects  that  may  produce  incomplete  sterility  are  so 
numerous  and  varied,  so  interactive  and  complicated,  that  they  some- 
times defy  analysis ;  they  may  be  designated  generally  as  follows  : 

1.  Inflammation  in  the  genital  tract  and  its  results,  such  as  dis- 
placements, adhesions,  pathological  secretions,  stenosis,  atresia,  kinking 
of  the  Fallopian  tubes,  atresia  of  the  cervix  uteri  or  vagina,  tubercu- 
losis and  syphilis  of  the  genital  tract,  hypertrophy  and  hyperplasia, 
atrophic  changes,  microcystic  degeneration  of  the  ovaries,  and 
mechanical  conditions. 

2.  Tumors  of  the  generative  organs,  and  the  organic  and  mechanical 
changes  that  the  tumors  produce. 

3.  Faulty  innervation  and  innutrition  of  the  organs  of  reproduc- 
tion.    Vaginismus  and  pruritus  vulvae  are  possible  examples. 

Discussion  of  Acquired  Sterility. — Surgical  Operations. — The 
surgical  removal  of  one  ovary  or  Fallopian  tube  does  not  cause 
sterility  ;  if  both  are  removed,  sterility,  except  possibly  in  rare  cases 
of  a  third  ovary,  is  absolute  ;  if  a  small  part  of  one  ovary  remains, 
pregnancy  may  occur.  The  removal  of  both  tubes  would  not  neces- 
sarily cause  sterility.  Pregnancy  has  followed  the  removal  of  both 
tubes  by  ligature  placed  close  to  the  uterus  ;  in  these  cases  the  ligatured 
stump  having  sloughed  off,  the  extreme  uterine  end  of  the  tube 
remained  sufficiently  open  to  transmit  the  ovum.  Excision  of  the 
uterine  ends  of  the  tubes  and  union  of  the  peritoneal  surfaces  over  the 
wounds  in  both  uterine  cornua  would  cause  absolute  sterility.  Preg- 
nancy may  occur  in  a  uterus  of  which  a  part  has  been  removed,  espe- 
cially the  cervical  part.  Even  considerable  portions  of  the  wall  of 
the    corpus,   as  in    myomectomy,  may   be   sacrificed  without  causing 


768  DISORDERS  OF  MENSTRUATION  AND  STERILITY. 

absolute  sterility.  There  is  a  recognized  persistence  in  the  ovaries, 
tubes,  and  uterus  that  sometimes  enables  them,  even  though  mutilated 
and  mostly  destroyed,  to  perform  the  reproductive  functions.  Numerous 
conservative  operations,  therefore,  designed  to  preserve  in  whole  or  in 
part  the  uterus  and  its  appendages,  have  been  substituted  for  the 
radical  operation  of  removal.  See  Myomectomy,  Salpingostomatomie, 
Resection  of  the  Ovary,  and  Vaginal  Incision  and  Drainage. 

Inflammatory  Disorders  of  the  uterus,  Fallopian  tubes,  or  ovaries  are 
associated  with  a  great  majority  of  cases  of  acquired  sterility.  Ovaritis 
may  result  in  atrophy  or  other  organic  changes  that  ^vill  render  the 
ovary  sterile  or  incapable  of  producing  mature  ova.  Atrophy  of  the 
ovaries,  general  or  acquired,  may  or  may  not  be  associated  with 
atrophy  of  the  uterus. 

Salpingitis  may  set  up  thickening,  adhesions,  kinking,  stenosis,  or 
atresia  of  the  tube,  and  in  this  way  may  impede  the  ovum  in  its  pass- 
age to  the  uterus  or  pathological  secretions  may  destroy  it.  Inflam- 
matory thickening  of  the  muscular  layer  may  embarrass  the  tube  in 
passing  the  ovum  toward  the  uterus.  Endosalpingitis  may  destroy 
the  cilia  of  the  tubal  epithelium,  so  that  they  cannot  aid  in  the  trans- 
mission of  the  ovum.  Catarrhal  salpingitis  may  cause  temporary 
obstruction  of  the  tube  from  swelling  of  the  mucosa. 

Endometritis  may  produce  a  pathological  secretion  so  abundant 
and  so  hostile  to  the  impregnated  ovum  as  to  prevent  implantation 
— may  even  destroy  it  and  sweep  it  out  of  the  uterus  ;  or,  if  imbed- 
ding take  place,  the  ovum  may  be  unable  to  survive  the  hostile 
environment. 

Sterility  caused  by  gonorrhoea!  or  syphilitic  salpingitis  and  endo- 
metritis may  be  relative  or  absolute  ;  more  frequently  the  latter.  This 
is,  perhaps,  a  wise  provision  of  nature  to  limit  reproduction  by  per- 
sons having  venereal  disease. 

Endocervicitis  produces  a  cervical  plug  of  gelatinous  mucus 
that  mechanically  prevents  the  ingress  of  spermatozoa  to  the  endo- 
metrium. 

General  metritis  even  more  than  endometritis  renders  the  uterus 
unfit  for  gestation. 

Exfoliative  endometritis  (membranous  dysmenorrhcea)  generally 
causes  complete  sterility. 

Pelvic  peritonitis  may  cause  obstruction  of  the  tube  by  closure  of 
the  fimbriated  extremity  ;  or  may  so  draw  it  aside  by  adhesions  that 
for  mechanical  reasons  it  may  fail  to  transmit  the  ovum. 

Parametritis,  although  apt  to  be  associated  with  inflammations 
elsewhere,  is  not  in  itself  a  very  significant  cause  of  sterility. 

Vaginitis  may  produce  a  hyperacid  secretion  that  is  hostile  to  the 
spermatozoa,  and  may  induce  incomplete  sterility  by  cicatricial  stenosis, 
or  by  adhesions  of  the  vaginal  portion  of  the  cervix  to  the  vaginal 
fornix,  or  by  cicatricial  shortening  of  the  vagina.  Vaginitis  and 
vulvovaginitis  prevent  coition  or  render  it  painful  and  imperfect,  and 
are  therefore  not  infrequent  causes  of  incomplete  sterility. 

Painful  caruncle  of  the  urethra  and  kraurosis  vulvae  are  other 
causes    of    dyspareunia   and    consequent    incomplete    sterility.     The 


STERILITY.  769 

presence  of  urine  in  the  vagina  from  a  vesicovaginal  fistula  ^vould 
destroy  spermatozoa,  both  by  its  own  toxins  and  by  the  vaginitis  that 
it  would  cause. 

Atrophy  of  the  uterus  may  be  either  concentric  or  excentric  ;  both 
cause  sterility,  the  former  more  positively  than  the  latter.  See  Atro- 
phy of  the  Uterus  in  chapter  on  Amenorrhoea.  Curettage  has  been 
followed  occasionally  by  atrophy  of  the  uterus. 

Tumors  of  the  genital  organs,  by  their  mechanical  effects  or  by 
their  depressing  systemic  influence,  may  induce  sterility  ;  but  they 
more  commonly  do  so  by  the  inflammatory  or  other  organic  changes 
which  they  set  up.  The  irritating  presence  of  a  uterine  myoma  caus- 
ing endometritis,  and  complete  destruction  of  ovarian  tissue  by  the 
presence  of  an  ovarian  tumor,  are  familiar  examples.  A  case  has 
been  reported  of  a  woman  who  had  given  birth  to  twelve  children,  of 
whom  the  last  was  only  three  months  old  at  the  time  of  the  removal 
of  two  dermoid  ovaries.  This  case  illustrates  the  fact  that  an 
ovarian  cyst,  although  it  may  cause  partial  sterility,  yet,  unless  it 
has  destroyed  the  entire  cortical  substance  of  the  ovary,  does  not 
cause  complete  sterility. 

Displacements  and  stenosis  of  the  uterus,  especially  flexions,  are 
associated  very  commonly  with  incomplete  sterility.  It  is  highly 
probable  that  these  lesions  cause  sterility  rather  from  associated  en- 
dometritis, salpingitis  and  perimetritis,  than  from  any  direct  influ- 
ence they  exert  pei'  se. 

The  above  statement  is  especially  true  of  pathological  anteflexion 
and  stenosis  of  the  os  uteri  externum.  Spermatozoa  will  pass  through 
very  minute  openings,  but  catarrhal  conditions  above  may  destroy 
them.  In  sounding  the  uterus  for  the  diagnosis  of  atresia  or  stenosis, 
care  should  be  taken  lest  the  sound,  by  catching  in  a  fold  of  cervical 
mucosa,  make  the  canal  appear  imperforate.  It  is  also  important  to 
observe  whether  the  sound  passes  on  by  pushing  aside  an  unrecognized 
valve-like  flap  of  mucosa,  which,  if  left  undisturbed,  might  give 
rise  to  obstruction. 

4.  Indeterminate  Causes. 

In  some  cases  the  reproductive  function  has  always  been  absent, 
or  is  suspended  or  lost  without  discoverable  cause.  These  cases 
occupy  an  indefinite  ground  between  absolute  and  contingent  steril- 
ity. To  say  that  there  is  imperfect  co-ordination  between  important 
organs  involved,  or  that,  owing  to  incompatibility,  the  husband  and 
wife  do  not  act  together  efficiently,  in  nowise  accounts  for  the  fail- 
ure. Absence  of  orgasm  on  the  part  of  the  woman  has  been  offered 
in  some  cases  as  an  explauation  ;  but  there  is  abundant  proof 
that,  although  it  may  have  some  influence,  orgasm  is  not  essential 
to  impregnation. 


770  DISORDERS   OF  MENSTRUATION  AND  STERILITY. 

Diagnosis,  Prognosis,  and  Treatment  of  Sterility. 

The  diagnosis,  prognosis,  and  treatment  of  the  symptoms  of  sterility 
necessarily  conform  to  the  various  diseases  that  give  rise  to  it ;  and 
are  set  forth  at  length  in  the  preceding  chapters  that  treat  of  those 
diseases.     To  those  chapters  the  student  is  referred. 

The  Diagnosis  includes,  first,  a  careful  examination  of  the  hus- 
band. If  the  fault  lies  with  him,  as  it  frequently  does,  the  case  is  not 
gynecological,  and  should  not  be  made  the  occasion  for  examination 
or  treatment  of  the  wife. 

In  examining  the  woman  for  sterility,  it  is  nsually  necessary  to 
make  not  only  a  careful  conjoined  examination  of  all  the  reproductive 
organs,  but  as  well  of  the  systemic  condition.  The  local  examination 
will  include  generally  accurate  measurements  with  the  sound  of  the 
length  and  diameter  of  the  uterine  canal. 

Prognosis. — Disease  associated  with  sterility  may  offer  a  favorable 
prognosis  for  anatomical  cure,  and  even  for  the  relief  of  pain  and  other 
annoying  symptoms  ;  such  a  result,  however,  not  always  is  associated 
with  successful  pregnancy.  The  prognosis  of  sterility,  therefore,  does 
not  necessarily  conform  to  that  of  the  associated  lesions. 

Treatment. — The  treatment  is  that  of  the  associated  lesions,  and 
is  in  no  respect  modified  by  the  fact  that  the  object  of  treatment  is 
impregnation.  The  indication  will  always  be  to  secure  an  open  gen- 
ital tract,  a  normal  state  of  the  reproductive  organs,  and  a  good  sys- 
temic condition.  The  treatment  of  sterility  by  mechanical  aids  to 
pregnancy,  such  as  the  transfer  of  seminal  fluid  from  the  vagina  to  the 
endometrium  by  injection  immediately  after  intercourse,  has  been 
tried ;  the  method,  however,  is  revolting  and  probably  useless. 


CHAPTER    LV. 

INCONTINENCE  OF  URINE  IN  WOMEN.^ 

This  discussion  is  confined  to  the  involuntary  escape  of  urine  through 
the  urethra.  Incontinence  due  to  acquired  urinary  fistula  or  to  any 
congenital  defect  of  the  urinary  tract  will  not  be  considered  here. 
Broadly  speaking,  from  the  point  of  view  of  the  causative  pathology, 
incontinence  has  been  classified  under  two  general  forms,  and  these 
forms  may  occur  singly  or  combined  ;  they  are  : 

1.  Active  incontinence. 

2.  Passive  incontinence. 

1.  Active  incontinence  is  due  either  to  a  hypertonic,  constricted,  or 
distended  state  of  the  bladder,  which  causes  the  urine  to  be  involun- 
tarily forced  out  through  a  urethra  which  under  ordinary  conditions 
would  have  adequate  sphincteric  power.  The  bladder  acts  to  a  vari- 
able extent  as  a  reservoir,  but  the  sphincter  is  inadequate  to  prevent 
involuntary  escape  of  urine.  Among  the  causes  of  this  form  of  incon- 
tinence are  abnormal  urine,  foreign  bodies,  tuberculosis,  cicatrices, 
tumors  of  the  bladder,  cystitis,  and  other  conditions  which  may  give 
rise  to  such  irritation  and  consequent  contraction  of  the  walls  of  the 
bladder  as  to  overcome  the  sphincteric  power  of  the  urethra  and  to 
force  out  urine.  Overflow  of  an  enormously  distended  bladder  or  of 
a  bladder  very  much  contracted  from  cystitis  and  having  thick,  un- 
yielding walls,  would  be  an  example  of  active  incontinence.  Further 
discussion  of  active  incontinence  does  not  fall  within  the  scope  of  this 
chapter, 

2.  Passive  incontinence  is  due  to  some  sphincteric  defect,  such,  for 
example,  as  traumatism  or  paralysis,  which  deprives  the  neck  of  the 
bladder  and  urethra  of  the  power  of  retention.  Complete  paralysis  of 
the  sphincter  which  causes  urine  to  escape  involuntarily  as  fast  as  it 
enters  the  bladder,  which  is  apt  to  be  of  spinal  origin  andconsequently 
associated  with  paralysis  of  other  parts,  such  as  the  bowel,  bladder, 
and  lower  extremities.  This  form  of  incontinence  also  will  be  ex- 
cluded from  further  discussion. 

The  present  purpose  is  to  consider  the  surgical  treatment  of 
another  and  frequent  variety  of  passive  incontinence  common  ii ;  mul- 
tiparous  women,  and  usually  due  to  the  traumatisms  or  other  results 
ot  parturition.  This  special  form  of  incontinence  is  always  character- 
ized by  a  very  appreciable  sagging  away  of  the  urethra  and  neck  of 
the  bladder  from  the  pubes,  and  by  a  dilated  sacculated  appearance  of 
the  urethra.     This  separation  of  the  urethra  from  the  pubes  is  often 

1  President's  address,  American  Gynecological  Society,  1905.  Journal  American  Medical 
Association,  June  3,  1905, 

77; 


772  INCONTINENCE  OF   URINE  IN   WOMEN. 

caused  by  a  crushing  or  tearing  of  it  from  the  symphysis  during  par- 
turition. The  condition  ordinarily  is  one  of  urethrocele  and  com- 
monly is  associated  with  more  or  less  cystocele,  laceration,  and  relaxa- 
tion of  the  perineum,  and  subinvolution  of  the  whole  vaginal  outlet. 
The  loss  of  urine  is  not  coustant,  but  is  occasional  or  frequent,  and 
occurs  as  a  result  of  coughing,  sneezing,  sudden  change  of  position, 
fright,  or  from  some  unassignable,  perhaps  neurotic,  condition.  The 
bladder  is  neither  distended,  as  in  cases  of  dribbling  from  overflow  of 
urine,  nor  constantly  empty,  as  in  passive  incontinence  from  paralysis 
of  the  sphincter,  but  normally  holds  more  or  less  urine  which  the 
patient  can  pass  or  retain  at  will.  The  condition  Mnll  be  recognized 
as  one  of  frequent  occurrence,  great  embarrassment  to  the  patient,  and 
difficulty  of  cure. 

Methods  of  Treatment. 

In  the  literature  up  to  the  present  time,  numerous  operations  and 
procedures  have  been  put  forward  for  the  relief  of  this  form  of  inconti- 
nence ;  excluding  those  not  specially  pertinent  to  the  subject,  they  are  : 

1.  Injection  of  paraffin  into  the  region  of  the  urethra. 

2.  Massage  and  electricity. 

3.  Torsion  of  the  urethra,  after  Gersuny. 

4.  Advancing  of  the  urethra,  after  the  method  of  Pawlik,  Hum- 
melfarb,  Albarran,  and  others.^ 

1.  Injection  of  paraffin,  even  if  it  gave  good  results,  which  it  does 
not,  would  be  prohibited  because  of  danger  to  life  from  pulmonary 
embolism. 

2.  Massage  and  electricity,  although  sometimes  temporarily  effec- 
tive, seldom  give  permanent  results. 

3.  Torsion  of  the  urethra,  after  the  method  of  Gersuny,  which 
requires  the  urethra  to  be  dissected  loose  from  its  surroundings  through- 
out its  length,  then  twisted  on  itself  from  180°  to  4^0°  and  sutured 
in  place,  is  apt  to  overcome  incontinence,  but  is  prohibited  on  account 
of  danger  from  sloughing  of  the  urethra. 

4.  The  advancing  of  the  urethra,  after  Pawlik's  method,  consists 
of  two  lateral  denudations,  one  on  either  side  of  the  urethra,  and 
suture  of  the  denuded  surfaces  in  such  a  manner  as  to  cause  the  ure- 
thra to  be  stretched  laterally  and  to  be  drawn  up  toward  the  mons 
veneris.  The  operation  is  performed,  according  to  Pawlik,  in  two 
parts,  the  wound  on  one  side  being  allowed  to  unite  firmly  before  that 
on  the  other  side  is  made.  This  operation  is  sound  in  principle — that 
is,  advancement  of  the  urethra — but  the  results  too  often  have  not  been 
permanent.  Pawlik  has  proposed  another  operation  in  some  respects 
similar  to  the  oneM'hich  I  shall  describe  later,  but  so  far  as  I  can  learn 
he  confines  the  application  of  it  to  cases  of  congenital  epispadias  and 
congenital  shortening  of  the  urethra.  Hummelfarb  lengthens  the 
urethra  by  union  of  the  labia  between  the  meatus  and  the  clitoris  in 
order  that  retention  may  be  secured  by  raising  the  meatus  above  the 

1  The  significant  literature  on  the  subject  dates  back  but  a  few  years  and  is  rather  meagre. 
I  am  indebted  to  Dr.  Heliodor  Schiller  for  numerous  references  to  articles,  mostly  German, 
which  during  the  past  thirty  years  have  appeared  in  the  periodical  literature,  many  of  which  I 
have  consulted. 


Figure  429. 


Operation  for  incontinence  of  urine ;  showing  denuded  surfaces  and  the  first  two  sutures  in 

place,  but  not  tied. 

47  773 


Figure  430. 


First  two  sutures  tied  and  meatus  urinarius  drawn  up  to  the  clitoris  and  fastened  there. 
The  arrows  here  show  the  margins  of  the  lateral  parts  of  the  wound  so  rotated  as  to  make  the 
sutures  hold  the  urethra  firmly  in  its  newly  acquired  elevated  position. 


Figure  431. 


Last  suture  being  introduced  to  complete  the  operation.  The  previously  sastjing  urethra 
is  here  shown  as  extended  and  held  firmly  up  against  the  pubes  in  its  normal" relations.  While 
the  lateral  sutures  are  being:  passed  it  is  well  to  have  the  meatus  stronelv  pulled  up  toward  the 
mons  veneris  by  means  of  a  tenaculum  hooked  into  it  and  held  in  the  hand  of  an  assistant. 


776  INCONTINENCE   OF   URINE  IN   W03IEN. 

level  of  the  urine  in  the  bladder.  Tlie  urethra  is  then  expected  to  act 
on  the  principle  of  the  spout  of  a  tea-kettle.  This  method,  earlier 
described  by  Emmet,  in  a  majority  of  cases  fails  on  account  of  the 
activity  of  the  contracting  bladder  forcing  out  urine  (active  inconti- 
nence) regardless  of  the  level  of  the  outlet.  Albarran's  operation 
consists  of  dissecting  free  the  urethra,  in  making  an  incision  from  the 
meatus  to  the  clitoris,  in  forming  two  flaps,  in  raising  the  urethra  to 
the  clitoris,  and  in  suturing  the  flaps  over  it.  This  operation  is  effec- 
tive unless,  as  sometimes  occurs,  freeing  of  the  urethra  from  its 
surroundings  gives  rise  to  sloughing. 

Proposed  Operation. 

The  operation  here  described  is  based  on  the  same  principle  as  that 
proposed  by  Albarran — that  is,  advancement  of  the  meatus  urinarius 
to  the  clitoris,  but  this  is  done  without  dissecting  the  urethra  free  and, 
therefore,  it  obviates  the  danger  of  sloughing  of  the  urethra ;  it  is 
performed  as  follows  in  two  steps  : 

First  ^tep. — A  liorseshoe-shaped  surface  is  rather  deeply  denuded 
between  the  meatus  urinarius  and  the  clitoris,  and  to  either  side  of  the 
urethra  throughout  the  entire  length  of  it,  as  shown  in  Figure  429. 

Second  Step. — The  meatus  is  drawn  up  to  a  point  near  the  clitoris 
and  is  secured  there  by  means  of  two  sutures  (Figures  429  and  430). 
The  lateral  portions  of  the  denuded  surface  are  now  closed,  as  shown 
in  Figure  431.  The  effect  of  the  operation  is  to  replace  and  to  retain 
in  its  functional  relations  the  sagging  displaced  urethra.  It  will  be 
observed  that  the  two  first  sutures  necessarily  stretch  the  urethra 
upward  to  the  region  of  the  clitoris  and  that  the  lateral  sutures  must 
tend  to  hold  it  in  its  new  position.  By  this  means  it  is  proposed  to 
straighten  out  the  urethrocele,  by  longitudinal  traction,  and  by  lateral 
traction  to  c(^llapse  and  to  hold  together  the  dilated  walls  of  the  ure- 
thra, and  thus  to  overcome  the  sacculation  at  the  neck  of  the  bladder 
where  residual  urine  is  apt  to  accumulate  and  give  rise  to  trigonitis, 
cystitis,  and  possible  incontinence. 

In  many  cases  it  will  be  necessary  to  combine  with  the  operation 
some  ap])ropriate  surgical  treatment  for  an  associated  cystocele,  and  in 
nearly  all  cases  to  perform  perineorrhaphy  to  relieve,  also,  relaxation 
of  the  posterior  vaginal  outlet.  In  one  case  I  saw  fit  to  narrow  the 
pouching  urethra  in  order  to  overcome  the  urethral  dilatation. 

I  have  performed  this  operation  many  times  and  with  almost  uni- 
formly gratifying  results.  In  one  case  there  was  so  much  relaxation  of 
the  skin  and  other  soft  parts  in  the  region  of  the  clitoris  that  I  feared 
the  sutured  urethra  might  pull  these  structures  down  to  the  old  mal- 
position instead  of  being  held  up  by  them,  but  so  far  it  remains  well  in 
place.  In  such  a  case  again,  or  in  the  event  of  recurrence  from  such 
a  cause,  however,  I  should  be  disposed  to  make  a  deep  oval  denuda- 
tion over  the  pubes  on  the  mons  veneris  just  above  the  clitoris,  the 
longer  axis  of  the  oval  being  directed  transversely,  and  to  unite  the 
margins  of  this  wound  by  a  transverse  line  of  union  so  as  to  make  the 
clitoris  a  fixed  point  on  a  sufficiently  high  plane  to  hold  the  urethra 


PROPOSED   OPERATION.  777 

taut.  For  obvious  reasons,  this  procedure  would  be  preferable  to  the 
removal  of  the  clitoris  and  the  union  of  the  meatus  to  the  parts  thereby 
exposed. 

The  operation  is  so  simple  that  I  have  been  rather  surprised  not  to 
find  myself  precisely  anticipated  in  every  particular,  but  so  far  as  I 
have  been  able  to  learn,  tiie  operation,  in  some  essential  respects  at 
least,  is  novel.  If  it  should  be  found,  however,  that  I  am  duplicating 
the  work  of  another,  I  desire  to  make  due  acknowledgment  in  advance. 


i:n"dex. 


A. 

Abdominal  drainage,  138 

comparison  of  results  of,  138 
evil  results  of,  139 

fecal  fistula,  139 
hernia,  139 
iodoform      poisoning, 

139 
obstruction  of  bowel, 

139 
vesical  complications, 
139 
forms  of  capillary,  142 
postular,  145 
tubular,  142 
vaginal,  145 
hysterectomy  for  hsematometra,  535 
radical,  in  carcinoma  of  uterus, 
423 
hysteromyomectomy,  complete,  for 

myoma  of  uterus,  394 
hysterorrhaphy,  702 

condition  of  successful,  705 
impediments  to,  703 
nomenclature  of,  703 
technique  of,  706 
incision  in  ovariotomy,  470 
myomectomy  for  myoma  of  uterus, 
386 
drainage  in,  388 
pregnancy,  486 
section,  40,  120 

adhesions  in,  124 
closure  of  wound  in,  126 

buried  sutures  in,  126 
curettage  in,  47 
dressings  and  bandages  in.  134 
incision  in,  122 

exploratory,  122 
median,  through  linea  alba, 
122 
intraperitoneal   hsemostasis  in, 
124 
sutures  in,  126 
Kelly's  pad  in,  48 

substitute  for.  48 
for  pelvic  inflammation,  291 
advantages  of.  328 
complications  of,  294 
Dudley's        operation 
for,  292 
preparation  for,  40 
of  assistants,  40 


Abdominal   section,  preparation  for,  of 
bowels,  45 
cleansing   of  external   pu- 
denda, 47 
of  vagina,  47 
by  drinking  of  water,  45 
of  hands,  40 
of  operator,  40 
preparatory  treatment  of,  122 
sponges  in,  129 

stitch-hole    abscesses    in,    pre- 
vention of,  46 
Trendelenburg's     position     in, 
120 
substitute  for,  122 
wound  of,  suppuration  of,  46 
wall,    fat    in,    differentiated    from 
ovarian  cyst,  462 
Abortion,  incomplete,  differentiated  from 
carcinoma  of  uterus,  417 
from  myoma  of  uterus,  377 
in  tubal  pregnancy,  490 
Abscesses,  stitch-hole,  prevention  of.  in 
abdominal  section,  46,  158 
suburethral,  complicating  urethritis, 
339 
treatment  of,  339 
vulvovaginal,  187 
Accessory  tubes  and  ostia,  513 

uterus,  514 
Acid,  carbolic,  as  an  antiseptic  agent,  36 
oxalic,  as  an  antiseptic  agent,  35,  41 
Adenocarcinoma  of  vulva.  361 
diagnosis  of.  361 
treatment  of.  362 
Adenomatous  cyst  of  ovary.  441 
Adenomyoma  of  Fallopian  tubes.  481 
Adhesions,  management  of,  296 
Adhesive  peritonitis,  283 
Alcohol  as  an  antiseptic  agent,  35 
Alexander's  operation,  691 

after-treatment  of.  699 
anchoring  of  ligaments  in.  696 
contraindications  for.  692 
drawing  out  the  ligament   in, 

695 
finding  the  ligament  in,  694 
incision  for,  693 
indications  for.  692 
landmarks  for.  693 
limited  scope  of,  699 
preparatory  treatment  for.  692 
for  prolapse  of  uterus.  666 
steps  in,  693 

779 


780 


INDEX. 


Allantois,  development  of,  505 

Amann     on    invagination     of     uterine 

glands,  226 
Amenorrhoea,  745 

causes  of,  general,  746 

local,  745 
classification  of,  745 
diagnosis  of,  746 
etiology  of,  745 
pathological,  23 
physiological,  23 
prognosis  of,  746 
symptoms  of,  746 
treatment  of,  747 
local,  747 
systemic,  747 
Amnion,   formation   of,   in   tubal   preg- 
nancy, 487 
Ampullar  pregnancy,  490 
Anesthesia  in  examination,  64 
Androgyny,  527 
Anovaginal  fistula,  626 
Anteflexion  of  uterus,  712 
acquired,  713 
classification  of,  713 
comphcations  of,  714 
congenital,  713 
course  of,  714 
developmental,  713 
diagnosis  of,  716 
etiology  of,  713 
normal,  712 
pathological,  712 
pathology  of,  713 
symptoms  of,  714 
urethral,  714 
uterine,  715 

dysmenorrhcea,  716 
endometritis,  716 
sterihty,  716 
vesical,  714 
treatment  of,  717 

of  complications,  717 

by  division  of  cervix  uteri, 

723 
by  Dudley's  operation,  723 
by  electricity,  719 
by  forcible  dilatation,  719 
by  local  massage,  719 
mechanical  indications  for. 

718 
by  pessaries,  718 
by  suppositories  of  opium, 
720 
Antelocation  of  uterus,  636 
diagnosis  of,  636 
symptoms  of,  636 
treatment  of,  636 
Anteversion  of  uterus,  710 
acquired,  713 
congenital,  710 
diagnosis  of,  711 
etiology  of,  710 
prognosis  of,  711 
symptoms  of,  710 
treatment  of,  711 


Antiseptic  agents,  35 
alcohol,  35 
carbolic  acid,  36 
formalin,  35 
heat,  35 

mercuric  bichloride,  36 
oxalic  acid,  41 

potassium  permanganate,  35 
soap,  36 

sodium  carbonate,  36 
sulphuric  ether,  35 
Antiseptics,  prophylactic  use  of,  35 

therapeutic  use  of,  35 
Anus,  atresia  of,  521 

aversion  of,  in  digital  examination, 

60 
examination  of,  78 

proctoscope  in,  78 
sigmoidoscope  in  78 
malformation  of,  520 
Approximation  in  trachelorrhaphy,  583 
Arteriosclerosis  of  chronic  metritis,  254 
Ascent  of  uterus,  635 

diagnosis  of,  636 
symptoms  of,  636 
treatment  of,  636 
Ascites,     differentiated     from     ovarian 

cysts,  466 
Asepsis  in  minor  manipulations,  hands, 
49 
instruments,  49 
patient,  49 
Aseptic  technique,  34 

vaginal  operations,  preparation  for, 
48 
Aspiration,  77 
Atresia  of  anus,  521 
of  urethra,  521 
of  vagina,  521 

inflammatory,  519 
Atrophic  cellulitis,  chronic,  262 
metritis,  252 

non-puerperal,  254 
puerperal,  253 
Auto-infection,  170 

B. 

Bacillus  aerogenes  capsulatus,  33 
coli  communis,  33 

in  acute  metritis,  208 
diphtherige,  33 
pyocyaneus,  33 
tuberculosis,  33 
typhosus,  33 
Bartholin's  glands,  development  of,  510 
Bed-pan,  substitute  for,  92 
Bicornate  uterus,  514 
Bladder,  care  of,  after  abdominal  opera- 
tions, 149 
curettage  of,  in  treatment  of  cystitis, 

354 
distended,  differentiated  from  ova- 
rian cysts,  462 
phantom,  88 
stone  in,  in  vesicovaginal  fistula,  598 


INDEX. 


781 


Bladder,  tumors  of,  485 
Bloodvessels,  infection  by,  169 
Bougies,  75 

graduated,  in  dilatation  of  uterus, 
112 
Bovee  on  paravaginal  hysterectomy,  423 
Bowels,  care  of,  after  abdominal  opera- 
tions, 149 
obstruction     of,     from     abdominal 
drainage,  139 
after  abdominal  operations,  155 
causes  of,  155 
diagnosis  of,  156 
prognosis  of,  156 
treatment  of,  156 
preparation  of,  for  abdominal  sec- 
tion, 45 
Bowman,  capsule  of,  development  of,  505 
Brandt's     method     in     retroversion     of 

uterus,  676 
Broad  ligament,  cysts  of,  449 

end-to-end    approximation    of, 

392,  408 
tumors  of,  482 
Brown's  method  of  treating  inversion  of 

uterus,  741 
Buboes  in  vulvitis,  180 
Bulbocavernous  muscle,  543 
Byrne  on  ignihysterectomy,  426 

c. 

Cachexia  in  carcinoma  of  uterus,  413 
Canal  of  Nuck,  development  of,  509 
Capillary  drainage,  142 
Capsule  of  Bowman,  development  of,  505 
Carbolic  acid  as  an  antiseptic  agent,  36 
Carcinoma  of  cervix  uteri,  diagnosis  of, 
415 
of  corpus  uteri,  diagnosis  of,  415 
of  endometrium,  235 
of  Fallopian  tubes,  481 
of  ovary,  436 
of  round  ligament,  483 
of  urethra,  484 
of  uterus,  411 

adenocarcinoma,  411 
cause  of  death  from,  419 
course  of,  412 
cylindrical  cell,  411 
diagnosis  of,  414 

differential,  416 

from  chronic  metritis, 

417 
from      endocervicitis, 

417 
from  endometritis,  417 
from   hypertrophy   of 

cervix,  417 
from  ichthyosis  uteri, 

417 
from  incomplete  abor- 
tion, 417 
from  laceration  of  cer- 
vix, 417 
from  myoma,  416 


Carcinoma  of   uterus,  diagnosis  of,  dif- 
ferential, from  ovar- 
ian cysts,  464 
from      retained      pla- 
centa, 416 
from  sarcoma,  416 
from  syphilis,  417 
from    tuberculosis    of 
uterus,  418 
extension  of,  419 
recurrence   after   removal, 
419 
etiology  of,  412 
extension  of,  411 
gland,  411 
pavement  cell,  411 
prognosis  of,  419 
symptoms  of,  412 
cachexia,  414 
hemorrhage,  413 
pain,  413 

uterine  discharge,  413 
visceral  disorders,  413 
treatment  of,  420 

hysterectomy  in,  421 

ignihysterectomy,  425 
mortality  of,  428 
operation  of  election, 

428 
paravaginal,  422 
radical        abdominal, 

423 
recurrence     of     carci- 
noma after,  428 
palliative,  429 
of  vagina,  365 

treatment  of,  365 
of  vulva,  361 

cylindrical-cell,  361 

treatment  of,  362 
pavement-cell,  361 
diagnosis  of,  361 
Caruncle  of  urethra,  334 
Case  records,  form  of,  52 
Casper's  cystoscope,  86 
Catarrhal  salpingitis,  273 
Catgut,  sterilization  of,  43 

by  chromic  acid  process,  44 
by  dry  heat  process,  44 
Cellular  tissue,  anatomy  of,  260 
Cellulitis,  chronic  atrophic,  262 
diffuse,  of  Pozzi,  261 
pelvic,  260 

acute  metritis  and,  209 
anatomy  of,  260 
diagnosis  of,  263 

differential,  265 
etiology  of,  260 
pathological  anatomy  of,  261 
pathology  of,  261 
prognosis  of,  266 
symptoms  of,  263 

consistence  of,  265 
form  of,  264 
immobility  of,  265 
location  of,  264 


782 


INDEX. 


Cellulitis,  pelvic,  symptoms  of,  pain  in, 
265 
relations  of,  265 
treatment  of,  266 
of  Stopfer,  263 
Cervical  epithelium,  mucous  patch  of, 
219 
myoma  of  uterus,  372 
Pervix  uteri,  carcinoma  of,  diagnosis  of, 
415 
division  of,  for  anteflexion  of 

uterus,  723 
erosions  of,  219 
papillary,  219 
simple,  219 
glands  of,  203 

glandular  enlargements  of,  219 
cystic,  220 
polypoid,  220 
hypertrophy  of,   differentiated 
from    carcinoma    of    uterus, 
417  _ 
laceration  of,  565 
causes  of,  565 
diagnosis  of,  576 

differential,  579. 

from    carcinoma, 
418 
false  cervix  in,  567 

apparent    hyper- 
trophy    and 
elongation     of, 
572 
cystic    degenera- 
tion in,  571 
descent  and  vagi- 
nal    reduplica- 
tion in,  569 
pathological 
anatomy  of,  572 
subinvolution  in, 
568 
pathological   anatomy   of, 

566 
prophylaxis  of,  579 
results  of,  566 
symptoms  of,  574 
treatment  of,  579 

atypical     lacerations, 

587 
resection  of  cervix,  587 
trachelorrhaphy       in, 
579 
af  ter-tr  e  a  t  m  e  n  t 

of,  592 
approximation 

in,  583 
curettage  in,  582 
denudation       in, 

583 
disinfection       in, 

582  _ 
immediate  opera- 
tion, 580 
instruments    for, 
581 


Cervix  uteri,  laceration  of,  treatment  of, 
trachelorrha- 
phy in,  hemor- 
rhage in,  585 
preliminary   dila- 
tation, 582 
preparatory 
treatment     of, 
580 
removal   of   cica- 
tricial plug  in, 
584 
results  of,  592 
secondary  opera- 
tion in,  580 
sutures  in,  585 
mucous  polypi  of,  218 
ulceration  of,  chronic  endocer- 

vicitis  and,  221 
vaginal  portion  of,  injuries  of, 
537 
Chancroidal  vulvovaginitis,  186 

treatment  of,  186 
Chloroform  in  minor  operations,  100 
Chorio-epithelioma  of  uterus,  434 
diagnosis  of,  434 
etiology  of,  434 
pathology  of,  434 
prognosis  of,  435 
symptoms  of,  434 
treatment  of,  435 
Chorion,   formation   of,   in   tubal   preg- 
nancy, 487 
Cirrhotic  metritis,  252 
Clarke,  J.  S.,  on  flushing  of  abdominal 
cavity,  140 
on  radical  abdominal  hysterectomy, 
423 
Clitoris,  development  of,  510 

malformations  of,  524 
Cloaca,  persistent,  522 
Cocaine  in  minor  operations,  100 
Colpeurynter  in  treatment  of  inversion  of 

uterus,  739 
Condyloma  of  vulva.     See  Papilloma  of 

vulva. 
Congenital  anteflexion  of  uterus,  713 
ante  version  of  uterus,  710 
displacement  of  ovary,  512 
gynatresia,  530 

diagnosis  of,  531 
pathological  results  of,  530 
prognosis  of,  534 
symptoms  of,  530 
treatment  of,  534 
hypertrophy  of  ovaries,  512 
retroflexion  of  uterus,  709 
retroversion  of  uterus,  709 
Conjoined  examination,  60 
rectal,  62 
rectovaginal,  64 
traction  as  an  aid  to,  64 
with  sound,  65 
Constrictor  vaginae  muscle,  543 
Corpus  luteum  cysts,  440 

uteri,  carcinoma  of,  diagnosis  of,  415 


INDEX. 


783 


Corpus  uteri,  glands  of,  202 
Crede's  ointment,  155 
CuUen  on  radical  abdominal   hysterec- 
tomy, 423 
Curettage  of  bladder  in  treatment  of  cys- 
titis, 354 
in  chronic  endocervicitis,  222 

endometritis,  243 
diagnostic,  77 
in  minor  operations,  115 

technique  of,  117 
in  myoma  of  uterus,  382 
in  trachelorrhaphy,  582 
Curettes,  dull,  118 
obstetric,  118 
placental,  118 
Recamier's,  118 
sharp,  118 
Thomas',  118 
Cystic  glandular  enlargements  of  cervix 

uteri,  219 
Cystitis,  340 

causes  of,  340 
exciting,  341 
predisposing,  340 
classification  of,  343 
anatomical,  343 
bacteriological,  344 
clinical,  345 
pathological,  344 
diagnosis  of,  342 

differential,  343 
etiology  of,  340 
exfoliative,  346 

etiology  of,  346 
symptoms  of,  346 
exudative,  346 
fissure,  347 
foreign-body,  347 
gonorrhoeal,  343 
instrumentation  in,  341 
leucoplakia,  348 
pathology  of,  342 
superficial,  345 
suppurative,  345 
treatment  of,  348 
medical,  349 
prophylactic,  348 
summary  of,  354 
surgical,  351 

curettage  of  bladder,  354 
dilatation  of  urethra,  352 
extravesical  operations  in, 

354 
lithotomy,  354 
lithotrity,  354 
vaginal  cystotomy,  352 
topical,  350 
tubercular,  343 
ulcerative,  345 

vesicovaginal  fistula  a  cause  of,  595 
Cystocele,  545 

in  lacerations  of  perineum,  545 
Cystoscope,  cylindrical,  80 
electrical,  85 
Kelly's,  80 


Cystoscope,  use  of,  85 
Cystotomy,  vaginal,  in  cystitis,  352 
Cysts,  adenomatous,  of  ovary,  441 
of  broad  ligament,  449 
examination  of,  68 
of  Fallopian  tubes,  467 
hydatid,  differentiated  from  ovarian 

cysts,  467 
intraligamentous,  of  ovary,  479 
ovarian,  438 

corpus  luteum  cysts,  440 
cystadenomata,  441 
papillary,  442 
simple,  441 
dermoid,  444 

complicated,  445 
simple,  444 
diagnosis  of,  456 
adhesions,  458 
differential,  459 

from  ascites,  466 
from  dilated  stomach, 

462 
from  distended   blad- 
der, 462 
from  fat  in  abdominal 

wall,  462 
from  fecal  accumula- 
tion, 462 
from  gestation  in  one 
horn    of    bifurcated 
uterus,  464 
from      hsematometra, 

465 
from    hydatid    cysts, 

467 
from  hydrometra,  467 
from  metritis,  467 
from     normal     gesta- 

rion,  463 
from  phantom  tumors, 

462 
from  physometra,  465 
from  pyometra,  465 
from  renal  tumors,  468 
from  tubal  pregnancv, 

463 
from  tympanites,  462 
from     uterine     carci- 
noma, 464 
sarcoma,  464 
of  malignancy,  458 
distinction  between  parovarian 

cyst  and,  459 
exploratory  incision  in,  459 
follicular,  439 

formation  of  pedicle  of,  446 
mode  of  development  of,  438 
multilocular,  438 
prognosis  of,  458 
removal  of,  460 

abdominal  incision  in.  460 
accidents  in,  479 
after-treatment  of,  479 
closure  of  wound  after,  479 
complications  of,  479 


784 


INDEX. 


Cysts,  ovarian,  removal  of,  drainage  in, 
479 
emptying  and  delivery  of 

cyst  in,  472 
ligature  of  pedicle  in,  479 
secondary  changes  in,  451 
infection,  451 

adhesion,  452 
suppuration,  452 
rupture  of,  453 
causes  of,  454 
diagnosis  of,  454 
prognosis  of,  454 
results  of,  454 
symptoms  of,  454 
treatment  of,  455 
twisting  of  pedicle,  452 
diagnosis  of,  453 
etiology  of,  453 
pathology  of,  453 
prognosis  of,  453 
treatment  of,  454 
symptomatology  of,  455 
unilocular,  438 
parovarian,     428,     436.     See     also 
Cysts,  ovarian, 
contents  of,  448 
distinction     between     ovarian 
cysts  and,  449 
pelvic,  differentiated  from  myoma  of 

uterus,  378 
of  round  ligament,  482 

diagnosis  of,  482 
treatment  of,  482 
tubo-ovarian,  450 
urethral,  187 
of  vagina,  364 

treatment  of,  365 
of  vulva,  363 

I>. 

Decidua,  formation   of,   in   tubal   preg- 
nancy, 487 
Decidual  endometritis,  234 
Deciduoma  adenomatoma,  434 
carcinomatosum,  434 
malignum,  434 

diagnosis  of,  434 
etiology  of,  434 
prognosis  of,  435 
symptoms  of,  434 
treatment  of,  435 
sarcomatosum,  434 
De  Lee  on  treatment  of  endometritis,  213 
Denudation  in  plastic  operations,  106 
in  trachelorrhaphy,  583 
in  vesicovaginal  fistula,  603 
Dermoid  cysts  of  ovary,  444 

complicated,  445 
simple,  444 
Descent  of  uterus,  637 
course  of,  645 
diagnosis  of,  645 

differential.  645 
etiology  and  mechanism  of,  637 


Descent  of  uterus,  pathology  of,  643 
prophylaxis  of,  646 
symptoms  of,  645 
treatment  of,  647 

change     in     direction     of 

vagina  in,  650 
by  elytrorrhaphy,  651 
general,  647 
hygiene,  647 
hysterectomy  in,  650 
hysterorrhaphy  in,  666 
local,  647 

narrowing  of  vagina  in,  650 
perineorrhaphy   in,    656 
by  pessaries,  648 
by  plastic  operations,  650 
Diagnostic  curettage,  77 
Digital  examination,  58 
conduct  of,  59 
e version  of  anus  in,  60 
left-handed  method,  58 
lightness  of,  58 
Dilatation  of  uterus,  77,  109 

diverging  instruments  in,    112 
forcible,  technique  of,  115 
graduated  bougies  in,  77,  112 
incision  in,  110 
Dudley's,  111 
Schroeder's  method,  1 10 
special     advantages     of     each 

method,  114 
by  steel  instruments,  77 
by  tents,  77,  111 
by  water  dilators,  77 
Dilators,  uterine,  77 
Diphtheria   bacillus    in    acute  metritis, 

208 
Diphtheritic  metritis,  209 
vulvovaginitis,  183 
treatment  of,  183 
Displacement,  congenital,  of  ovary,  512 
of  uterus,  627 

definition  of,  631 
diagnosis  of,  631 
general  consideration  of,  627 
nomenclature  of,  631 
symptoms  of,  631 
Doderlein  on  lactic  acid  bacteria  in  vagi- 
nitis, 178 
Douche,  action  of,  93 

as  cleansing  agent,  93 
as  vascular  stimulant,  93 
application  of,  92 
contraindications  for,  93 
indication  for,  93 
Drainage,  abdominal,  138 

comparison  of  results  of,  138 
evil  results  of,  139 

fecal  fistula,  139 
hernia,  139 
iodoform      poisoning, 

139 
obstruction  of  bowel, 

139 
vesical  complications, 
139 


INDEX. 


Y»0 


Drainage,  forms  of,  142 
abdominal,  145 
capillary,  142 
pustular,  145 
tubular,  142 
vaginal,  145 
peritoneal,  contraindications  for,  142 

indications  for,  142 
to  prevent  infection,  139 
tubes,  glass,  144 
Reid's,  143 
rubber,  144 
Dress,  relation  of,  to  diseases  of  women, 

159 
Dressings,  antiseptic,  44 
aseptic,  44 
sterilization  of,  43 
Ducts  of  Mueller,  development  of,  507 
Dudley's   clamp   operation   for  uretero- 
vaginal  fistula,  109 
incision    in    dilatation    of    uterus, 

111 
on    end-to-end    approximation    of 

broad  ligaments,  392 
instrument  case,  38 
operation  for  anteflexion  of  uterus, 
723 
for  double  uterus,  514 
for  oophorectomy,  291 
sterilizer,  38 
Dysmenorrhoea,  756 

associated  lesions  of,  757 

classification  of,  756 

clinical  history  of,  756 

due  to  anteflexion  of  uterus,  716 

treatment  of,  760 


E. 

Ectodermal  layer,  434 
Eczema  of  vulva,  192 

treatment  of,  192 
Edebohl's      enteroptosis      complicating 

descent  of  uterus,  666 
Elephantiasis  of  vulva,  358 
diagnosis  of,  358 
treatment  of,  359 
Elytrorrhaphy  in  treatment  of  descent  of 
uterus,  651 
contraindications,  655 
Embryonic  structures,  development  of, 

into  organs,  508 
Emmet's  button-hole  operation,  335 
method  of  treatment  in  inversion  of 

uterus,  738 
operation  for  prolapse   of  urethra, 

338 
pessary,  688 
scissors,  101 
Emphysematous  vaginitis,  190 

treatment  of,  191 
Enchondroma  of  vulva,  364 
Endocervicitis,  chronic,  217 
diagnosis  of,  220 

digital  examination  in,  220 


Endocervicitis,  chronic,  diagnosis  of,  ex- 
aminations of  secretions 
in,  221 
sight  examination  in,  220 
speculum  examination  in, 
221 
etiology  of,  217 
pathology  of,  218 
sequence  of,  218 
symptoms  of,  220 
treatment  of,  221 

by  curettage,  222 
Schroeder's   operation    in, 
222 
differentiated    from    carcinoma    of 

uterus,  417 
polypoid,  224 
Endometritis,  chronic,  226 

classification  of,  226 
clinical,  231 
diagnosis  of,  236 

differential,  236 
dysmenorrhoea  and,  757 
etiology  of,  226 
histological  forms  of,  228 
pathology  of,  226 
prognosis  of,  237 
symptoms  of,  234 
abortion,  234 
hypersecretion,  234 
pain,  234 

reflex  disorders,  235 
sterility,  234 
systemic  disorders,  235 
treatment  of,  238 
surgical,  243 

curettage  in,  243 

indications      for, 

243 
regeneration      of 
endometrium 
after,  248 
technique  of,  244 
systemic,  238 

aniemia  in.  239 
constipation  in,  239 
general  hygiene  in,  240 
kidneys  in,  239 
topical,  240 

intra-uterine    tampon 
in.  242 
decidual,  234 
differentiatetl    from    carcinoma    of 

uterus,  417 
due  to  anteflexion  of  uterus,  715 
exfoliative,  232 
glandular,  228 

hyperplastic,  229 
hypertrophic,  228 
interstitial  and,  230 
hemorrhagic,  229 
interstitial,  229 
post-abortum,  232 
senile,  232 
treatment  of.  214 
tubercular,  233 


'S6 


INDEX. 


Endometrium,  202 

applications  to,  247 

of  carbolic  acid,  247 
of  formalin,  247 
of  iodine,  247 
carcinoma  of,  235 
mucous  polypi  of,  230 
regeneration  of,  after  curettage,  248 
sarcoma  of,  237 
Endosalpinx,  269 
Endothelioma  of  uterus,  430 
diagnosis  of,  430 
pathology  of,  430 
treatment  of,  430 
End-to-end     approximation     of     broad 

ligaments,  392,  408 
Enteroptosis    complicating    descent    of 

uterus,  666 
Enucleation  of  myoma  of  uterus,  384 
Epididymis,  development  of,  509 
Episiotomy,  541 
Epispadias,  524 

Epoophoron,  development  of,  509 
Erosions  of  cervix  uteri,  219 
papillary,  219 
simple,  219 
Erysipelas  malignum  internum  of  Vir- 

chow,  261 
Erysipelatous  vulvovaginitis,  182 
erythematous,  182 
gangrenous,  182 
treatment  of,  183 
vesicular,  182 
Ether  in  minor  operations,  100 
Eversion  of  anus  in  digital  examination, 

60 
Examination,  ansesthesia  in,  64 
of  anus,  78 

proctoscope  in,  78 
sigmoidoscope  in,  78 
of  ascites,  69 
by  auscultation,  66 
conjoined,  60 
rectal,  62 
rectovaginal,  64 
traction  as  an  aid  to,  64 
vaginal,  60 
with  sound,  65 
of  cysts,  68 
by  digital  touch,  58 

conduct  of,  59 
eversion  of  anus  in,  60 
left-hand  method,  58 
lightness  of,  58 
exploratory  incision  in,  90 
by  inspection,  57 
instrumental,  68 

diagnostic  curettage,  77 
exploratory  needle  and  aspira- 

cor,  77 
probe  in,  75 
sound  in,  75 

dangers  of,  76 
speculum  in,  68 
Simon's,  73 
Sims',  69 


Examination,  instrumental,  speculum  in, 
Sims'  self-retaining,  70 
uterine  dilatation,  77 
by  palpation,  66 
by  percussion,  66 
physical,  56 

bladder  in,  56 
cleanliness  in,  56 
position  of  patient  in,  57 
rectum  in,  56 
table  for,  56 
of  young  girls,  57 
of  rectum,  78 

proctoscope  in,  78 
sigmoidoscope  in,  78 
of  urinarj''  organs,  78 

catheterization  in,  80 
cystoscopy  in,  80 

comparison  of,  86 
cylindrical,  SO 
electrical,  85 
value  of,  86 
dorsal  position  in,  81 
inspection  in,  78 
knee-breast  position  in,  83 
palpation  in,  78 
percussion  in,  78 
segregation  in,  89 
urethral  exploration  in,  80 
urethroscopy  in,  80 
urinalysis  in,  78 
of  uterine  tumors,  67 
Excretory  organs,  embryology  of,  503 
Exfoliative  cystitis,  346 
etiology  of,  346 
symptoms  of,  346 
endometritis,  232 
Extra-uterine  pregnancy.        See  Tubal 

pregnancy. 
Exudative  cystitis,  346 
peritonitis,  283 


F. 

Facies  ovariana,  455 
Fallopian    tubes,     conservative    opera- 
tion on,  330 
development  of,  506 
inflammation  of,  268 
malformation  of,  513 
senile  changes  in,  29 
tumors  of,  481 
Fecal  accumulation  differentiated   from 
ovarian  cyst,  462 
fistula    from    abdominal    drainage, 
139,  157 
Fibroma  of  ovary,  436 

of  round  ligament,  482 

diagnosis  of,  482 
treatment  of,  482 
Fibromyoma  of  vagina,  365 
of  vulva,  363 

treatment  of,  363 
Fissure  cystitis,  347 
Fistula,  anovaginal,  626 


INDEX. 


787 


Fistula,    fecal,    after   abdominal   opera- 
tions, 157 
genital,  priority  in  operation  for,  593 

varieties  of,  594 
rectovaginal,  625 
causes  of,  625 
diagnosis  of,  625 
prognosis  of,  625 
treatment  of,  625 
ureterovaginal,  618 
causes  of,  618 
diagnosis  of,  618 
treatment  of,  618 

Dudley    clamp    operation 
in,  619 
urethrovaginal,  618 
vesico-uterine,  617 
diagnosis  of,  617 
treatment  of,  617 
vesico-uterovaginal,  593,  594 
vesicovaginal,  594 

cause  of  cystitis,  595 
course  of,  595 
diagnosis  of,  595 
etiology  of,  594 
prognosis  of,  595 
symptoms  of,  595 
treatment  of,  prophylactic,  596 
surgical,  597 

atypical      operations, 

609 
kolpokleisis,  611 
loss   of   entire  vesico- 
vaginal septum,  609 
operations  for  closing, 
601 
after-treatment 

of,  608 
application  of  su- 
tures in,  606 
choice   of   specu- 
lum, 602 
direction  of  line  of 

union  in,  603 
denudation       in, 

603 
method  of  opera- 
tion, 602 
p  reparatory 
treatment,  602 
preparatory,  597 
cystitis  in,  598 
direction  and 

manner      of 
closure,  598 
phosphatic       de- 
posits in,  597 
stone   in   bladder 
in,  598 
Flemming's      operation      for      artificial 

vagina,  535 
Flexion  of  uterus,  709 
Foetus,  calcareous  degeneration  of,  493 

mummified,  493 
Follicular  ovarian  cysts,  439 
vulvovaginitis,  189 


Foreign    bodies    in    uterus,    a   cause   of 
hemorrhage,  752 

Foreign-body  cystitis,  347 

Formalin  as  an  antiseptic  agent,  35 

Fowler's  position  in  abdominal  drainage, 
145 

Freund  on  radical  abdominal  hysterec- 
tomy, 423 

Furuncular  vulvitis,  190 

treatment  of,  190 

Furunculosis,  190 

treatment  of,  by  yeast,  190 

G. 

Gaertner's  duct,  446 

development  of,  505 
Garrigues  on  diphtheritic  metritis,  209 

on  dissecting  metritis,  209 
Gauze,  sterilization  of,  45 
Gellhorn  on  paravaginal   hysterectomy, 

422 
Generative  organs,  embryology  of,  507 
Genital  fistulse,  priority  in  operation  for, 
593 
varieties  of,  594 
glands,  development  of,  505 
ridge,  development  of,  503,  508 
Gestation,   normal,   differentiated   frofn 
ovarian  cysts,  463 
in  one   horn  of   bifurcated   uterus, 
differentiated  from  ovarian  cysts, 
464 
Giraldes,  organ  of,  development  of,  509 
Glands  of  cervix  uteri,  203 
of  corpus  uteri,  202 
Nabothian,  219 
Skene's,  inflammation  of,  334 
uterine,  invagination  of,  226 
Glandular  endometritis,  228 
hyperplastic,  229 
hypertrophic,  228 
interstitial  and,  230 
enlargements  of  cervix  uteri,  219 
cystic,  220 
polypoid,  220 
vulvovaginitis,  177,  187 
diagnosis  of,  187 
treatment  of,  187 
Gleet,  168 

Goitre  of  puberty,  28 
Gonococcus,  33 

of  Neisser,  167 
Gonorrhoea,  latent,  187 

transmission  of,  168 
Gonorrhoeal  cystitis,  343 
papilloma  of  vulva,  360 
urethritis,  333 
vaginitis  in  children,  181 
vulvovaginitis,  181 
diagnosis  of,  181 
treatment  of.  181 
warts  of  vulva,  360 
Graafian  follicles,  anatomy  of,  25 
Gubernaculum  of  Hunter,  development 
of.  507 


788 


INDEX. 


Gynandiy,  527 
Gynatresia,  congenital;  530 

diagnosis  of,  531 

patiiological  results  of,  530 

prognosis  of,  534 

symptoms  of,  530 

treatment  of,  534 


H. 

HEMATOCELE,    pelvic,    resulting    from 

tubal  pregnancy,  494 
Hsematocolpos,  530 

operations  for,  535 
Hsematoma  of  vulva,  358 
Hsematometra,  differentiated  from  ova- 
rian cysts,  465 
operations  for,  534 
Hsematosalpinx,  271,  530 
Hair,  sterilization  of,  42 
Harris,  segregator  of,  89 
Heat  as  an  antiseptic  agent,  35 
Hemorrhage  in  carcinoma  of  uterus,  413 
in  major  operations,  151 
diagnosis  of,  151 
treatment  of,  151 
in  myoma  of  uterus,  373 
^       in  trachelorrhaphy,  585 
uterine,  750 

diagnosis  of,  753 
during  maturity,  754 
menopause,  754 
etiology  of,  750 
of  girls,  753 
treatment  of,  754 

electrotherapeutic,  755 
local,  755 
surgical,  755 
systemic,  754 
Hemorrhagic  endometritis,  229 
Hermaphrodism,  527 
treatment  of,  528 
Hernia  from  abdominal  drainage,  139 
inguinal,  188 
of  ovary,  742 

diagnosis  of,  742 
treatment  of.  742 
of  uterus,  640,  742 
diagnosis  of,  742 
treatment  of,  742 
ventral,  after  abdominal  operations, 
158 
Herpes  of  vulva,  192 
Hunter,  gubernaculum  of,  development 

of,  507 
Hydatid  cysts,  differentiated  from  ovar- 
ian cysts,  467 
of  Morgagni,  development  of,  510 
Hydrocele,  ovarian,  450 
of  round  ligament,  482 

differential     diagnosis     of, 

482 
treatment  of,  482 
Hydrometra,  differentiated   from  ovar- 
ian cysts,  465 


Hydrosalpinx,  271 

aspiration  of,  through  vagina,  324 
technique  of,  324 
Hydro-ureter,  355 
Hymen,  malformation  of,  520 
Hypersesthesia  of  vulva,  199 

treatment  of,  200 
Hyperplastic  glandular  endometritis,  229 
Hypertrophic     glandular    endometritis, 
228 
metritis,  251 

non-puerperal,  251 
puerperal,  251 
Hypertrophy  of   cervix,   differentiated 
from  carcinoma  of  uterus,  417 
of  clitoris,  524 
congenital,  of  ovaries,  512 
of  prepuce,  526 
Hypodermoclysis   in   major   operations, 

151 
Hypospadias,  523 

operative  treatment  of,  523 
Hysterectomy,  abdominal,  for  hsemato- 
metra, 535 
for  procidentia,  650 
in  treatment  of  carcinoma  of  uterus, 
421 
ignihysterectomy,  425 
paravaginal,  422 
radical  abdominal,  423 
of  inversion  of  uterus,  742 
of  pelvic  inflammation,  indica- 
tions for,  305 
objections  to,  304 
vaginal,  of  myoma  of  uterus,  383 
Plysterical    vomiting    after    abdominal 
operation,  155 
treatment  of,  155 
Hysteromyomectomy,  complete  abdomi- 
nal, for  myoma  of  uterus,  394 
supravaginal,  for  myoma  of  uterus, 
391 
disinfection  of  vagina  in,  391 
Hysterorrhaphy,  abdominal,  702 

conditions  of  successful,  705 
impediments  to,  704 
nomenclature  of,  703 
technique  of,  706 
for  prolapse  of  uterus,  666 
vaginal,  708 

technique  of,  708 

I. 

Ichthyosis     of     uterus,     differentiated 

from  carcinoma,  417 
Ignihysterectomy  in  carcinoma  of  uterus, 
425 
advantages  of,  427 
history   and   rationale   of, 
426 
Incontinence  of  urine,  771 
treatment  of,  772 
surgical,  776 
Infantile  uterus,  22,  513 
vulva,  524 


INDEX. 


789 


Infection,  32 

by  blood-vessels,  169 

by  continuity  of  surface,   169 

forms  of,  32 

bacillus  coli  communis,  33 

tuberculosis,  34 
gonococcus,  33 
pyaemia,  33 
saprajmia,  33 
septicaemia,  32 
staphylococcus,  33 
Streptococcus  pyogenes,  33 
toxajmia,  32 
by  lymph- vessels,  169 
Inflammations,  165 

classification  of,  170 
acute,  171 
chronic,  171 
course  of,  169 
definition  of,  165 
diagnosis  of,  173 
etiology  of,  166 

exciting  causes,  167 
favoring  conditions,  166 
of  Fallopian  tubes,  268 
pathology  of,  169 
■     pelvic,  257 

etiology  of,  258 
routes  of  infection,  257 

by  blood-vessels,  257 
by       continuity       of 

mucosa,  257 
from    extra  pelvic 

organs,  257 
by  lymph-vessels,  257 
significance  of,  258 
prognosis  of,  173 
of  Skene's  glands,  333 
treatment  of,  173 
of  uterine  appendages,  268 
of  uterus.     See  Metritis, 
of  vulvovaginal  glands,   187 
Inflammatory  atresia  of  vagina,  519 
Inguinal  hernia,  188 
Instrument  cases,  37 

combination,  38 
Dudley's,  38 
pouches,  37 
trays,  37 
Instrumental  examination,   68 

diagnostic  curettage  in,  77 
exploratory  needle  and  aspira- 
tion in,  77 
probes  in,  75 

dangers  of,  76 
sounds  in,  75 

dangers  of,  76 
speculum  in,  68 
Simon's,  73 
Sims',  69 

self-retaining,  70 
uterine  dilatation  in,  77 
pain,  761 
Instruments,  diverging,  in  dilatation  of 
uterus,  112 
sterilization  of,  42 
48 


Interstitial  endometritis,  229 
metritis,  252 
tubal  pregnancy,  489 
Intra-abdominal    shortening    of    round 
ligament  in  retroflexion  and  retrover- 
sion of  uterus,  700 
Intraligamentous  cysts  of  ovary,  479 
Intramural  myoma  of  uterus,  369 
Inversion  of  uterus,  729 
anatomy  of,  732 
diagnosis  of,  733 
etiology  of,  729 
mechanism  of,  732 
pathology  of,  732 
prognosis  of,  735 
symptoms  of,  733 
treatment  of  acute,  735 
of  chronic,  736 

by  colpeurynter,  739 
by     elastic     pressure, 

739 
by  hysterectomy,  742 
by  inci.sion,  741 

Brown's  method, 
741 
manual,  738 

Emmet's  method, 

738 
Tate's  method, 
739 
preparatory,  737 
by  spiral  spray,  741 
White's    method, 
741 
by  water-bag,  739 
varieties  of,  735 
Ischiorectal  fascia,  543 
Isthmic  pregnancy,  4^0 

K. 

Kelly's  cystoscope,  80 

method  of  rectal  examination,  52 
pad  in  abdominal  section,  48 
substitute  for,  48 
Kidney,  floating,  differentiated  from  my- 
oma of  uterus,  379 
glomeruli  of,  development  of,  505 
King  on  treatment  of  endometritis,  213 
Kobelt's  tubules,  446 
Kolpokleisis  for  vesicovaginal  fistula,  611 
Kraurosis  of  vulva,  193 

pathology  of,  193 
treatment  of,  194 

Longyear's  operation,  194 
Kroemer  on  paravaginal  hysterectomy, 

423 
Kundrat  on  paravaginal  hysterectomy, 
423 

li. 

Labia  majora,  development  of,  510 

minora,  adhesions  of.  177 
Laceration  of  cervix  uteri,  565 
causes  of,  565 


790 


INDEX. 


Laceration  of  cervix  uteri,  diagnosis  of, 
575 
differential,  579 

from    carcinoma, 
417 
false  cervix,  567 

apparent    hyper- 
trophy        and 
elongation     of, 
572 
cystic       degener- 
ation in,  571 
descent  and  vagi- 
nal   reduplica- 
tion, 569 
pathological  anat- 
omy of,  572 
subinvolution, 
568 
pathological    anatomy    of. 

566  . 

prophylaxis  of,  579 
results  of,  566 
symptoms  of,  574 
treatment  of,  579 

atypical     lacerations, 

resection  of  cervix,  587 
trachelorrhaphy       in, 
579 
after-treatment 

of,  592 
approximation 

in,  583 
curettage  in,  582 
denudation       in, 

583 
disinfection       in, 

582 
hemorrhage      in, 

585 
immediate  opera- 
tion, 580 
instruments     for, 

581 
preliminary   dila- 
tation in,  582 
preparatory,  580 
removal   of   cica- 
tricial plug  in, 
584 
results  of,  592 
secondary  opera- 
tion, 580 
sutures  in,  585 
of  perineum,  540 

complete,  541,  544 
incomplete,  543 
prevention  of,  541 
results  of,  542 
Lactic  acid  bacteria  in  vaginitis,  178 
Langhans,  layer  of,  434 
Lateral  location  of  uterus,  636 
diagnosis  of,  636 
symptoms  of,  636 
treatment  of,  636 


Leiter's  cystoscope,  84 
Leucoplakia  cystitis,  348 
Lipoma  of  vulva,  363 

treatment  of,  363 
Lithopsedion,  493 

Lithotrity  in  treatment  of  cystitis,  354 
Longyear's  operation  for  kraurosis  vul- 
vae, 194 
Lord,  F.  H.,  douche  of,  92 
Lupus  of  vulva,  183,  363 
Lutein  cells,  440 
Lymphatics  of  uterus,  204 
Lymph-vessels,  infection  by,  169 

M. 

Mackenrodt   on  paravaginal  hysterec- 
tomy, 423 
Major  operations,  120 

abdominal  section,  120 

adhesions  in,  124 
closure  of  wound  in, 
126 
buried       su- 
tures     in, 
126 
dressings    and    band- 
ages in,  134 
incision  in,  122 

exploratory,  122 
median,    through 
linea  alba,  122 
intraperitoneal  hsemo- 
stasis,  124 
sutures  in,  125 
preparatory         treat- 
ment of,  122 
sponges  in,  129 
Trendelenburg      posi- 
tion in,  120 
substitute 
for,  122 
after-treatment  of,  148 

complicated  cases,  150 

fecal    fistula    in, 

157 
hemorrhage      in, 

151 
hysterical  vomit- 
ing, 155 
obstruction        of 

bowels,  155 
removal     of     su- 
tures in,  158 
sepsis  in,  153 
general,  154 
localized,  153 
shock  in,  150 
stitch-abscess   in, 

158 
ventral  hernia  in, 
158 
simple  cases,  148 

care    of    bladder, 
149 
bowels,  149 


INDEX. 


791 


Major    operations,    after-treatment    of, 

simple      cases, 

care  of  cicatrix, 

150 

food  in,  150 

getting  up  in,  150 

hot-water      bags, 

149 
pain  in,  150 
rest,  148 
thirst,  149 
drainage  in,  138 

comparison   of   results   of, 

138 
evil  results  of,  139 

fecal  fistula,  139 
hernia,  139 
obstruction        of 

bowel,  139 
vesical  complica- 
tions, 139 
forms  of,  142 

abdominal,  145 
capillary,  142 
postural,  145 
tubular,  142 
vaginal,  147 
peritoneal       contraindica- 
tions for,  142 
indications  for,  142 
to   prevent   infection, 
139 
in  sacral  resection,  137 
in  vaginal  section,  136 
Malformations  of  anus,  520 
of  clitoris,  524 
of  Fallopian  tubes,  513 
of  hymen,  520 
of  nymphse,  524 
of  ovaries,  511 
of  prepuce,  524 
of  uterus,  513 
of  vagina,  518 
of  vulva,  520 
Mal-locations  of  uterus,  635 
Marion-Sims  operation  for  genital  fistula, 

593 
Maturity,  period  of,  28 

uterine  hemorrhage  during,  754 
Menopause,  basis  of,  29 
phenomena  of,  30 
symptoms  of,  30 
abnormal,  30 
normal,  30 
uterine  hemorrhage  during,  754 
Menorrhagia.     See  Uterine  hemorrhage. 
Menstrual  discharge,  duration  of,  24 

quantity  of,  24 
Menstruation,  age  of  first,  23 
anatomy  of,  24 
disorders  of,  743 
frequency  of,  30 
periodicity  of,  25 
phenomena  of,  23 
general,  23 
local,  23 


Menstruation,  precocious,  24 
premature,  743 
causes  of,  744 
treatment  of,  744 
protracted,  24 
scanty,  24,  749 
Mercuric  biclilorid  as  an  antiseptic  agent, 

35 
Mesonephros,  development  of,  504 

glomeruli  of,  development  of,  505 
Metanephros,  development  of,  504 
Metritis,  202 
acute,  207 

bacillus  coli  communis  in,  208 
causes  of,  207 

bacterial,  208 
existing,  207 
predisposing,  207 
diagnosis  of,  210 
etiology  of,  207 
gonococcus  of  Neisser  in,  208 
pathology  of,  208 
perilymphangitis  and,  209 
periphlebitis  and,  209 
prognosis  of,  211 
pyaemia  in,  212 
sapreemia  in,  211 
septicaemia  in,  211 
staphylococcus  in,  208 
streptococcus  in,  208 
symptoms  of,  210 
treatment  of,  211 
abortive,  211 
expectant,  212 
palliative,  212 
prophylactic,  211 
surgical,  212 
atrophic,  252 

non-puerperal,  254 
puerperal,  253 
chronic,  250 

arteriosclerosis  of,  254 
diagnosis  of,  255 

differential,  255 

from      carcinoma     of 
uterus,  417 
dysmenorrhoea  and,  758 
etiology  of,  250 
pathology  of,  251 
physical  signs  of,  255 
symptoms  of,  255 
treatment  of,  256 
cirrhotic,  252 
classification  of,  205 
anatomical,  205 
etiological,  205 
pathological,  205 
differentiated      from      myoma      of 
uterus,  387 
from  ovarian  cysts,  465 
diphtheritic,  209 
dissecting,  209 
hypertrophic,  251 

non-puerperal,  251 
puerperal,  251 
interstitial,  252 


792 


INDEX. 


Metritis,  nomenclature  of,  206 
puerperal,  treatment  of,  215 
with  alcohol,  215 
with  antistreptococcic  se- 
rum, 215 
with  argentum    coUoidale, 

215 
with  Crede's  ointment,  215 
with  creolin,  215 
by  gauze  curettage,  215 
by  irrigation,  215 
Metrorrhagia.     See  Uterine  hemorrhage. 
Microcystic  degeneration  of  ovary,  440 
Minor  manipulations,  asepsis  of,  49 
of  hands,  49 
of  instruments,  49 
of  patient,  49 
operations,  99 

anaesthesia  in,  100 
chloroform,  100 
cocaine,  100 
ether,  100 
salt  water,  101 
curettage  in,  115 

technique  of,  117 
dilatation  of  uterus,  109 

diverging  instruments 

in,  112 
forcible,  technique  of, 

115 
graduated  bougies  in, 

112 
incision  in,  110 
Dudley's,  111 
Schroeder's 
method,  110 
special  advantages  of 

each  method,  114 
tents  in.  111 
during  pregnancy,  105 
instruments  in,  101 
scissors,  101 
sponge-holders,  103 
uterine  tenaculum,  103 
multiple,  105 
plastic,  106 

after-treatment  of,  109 
application  of  sutures  in, 

107 
assistants  in,  109 
denudations  in,  106 
needles  in,  107 
removal  of  sutures,  109 
union  by  first  intention  in, 
106 
preparatory  treatment  for,  99 
Staffordshire  knot,  118 
tables  for,  99 
Mittelschmerz,  761 
Moles,  uterine,  a  cause  of  hemorrhage, 

752 
Morcellation  of  myoma  of  uterus,  384 
Morgagni,  hydatid  of,  development  of, 

510 
Mucous  polypi  of  cervix  uteri,  218,  219 
of  endometrium,  230 


Mucous  polypi  of  urethra,  484 
Mueller,  ducts  of,  development  of,  507 
Multilocular  ovarian  cysts,  438 
Mycotic  vulvovaginitis,  184 
diagnosis  of,  184 
etiology  of,  184 
prognosis  of,  184 
symptoms  of,  184 
treatment  of,  185 
Myoma  of  Fallopian  tubes,  481 
of  ovary,  436 
of  round  ligament,  482 

diagnosis  of,  482 
treatment  of,  482 
of  uterus,  366 

classification  of,  369 
cervical,  372 
intramural,  369 
submucous,  370 
subperitoneal,  372 
complete    abdominal    hystero- 
myomectomy 
for,  394 
technique  of,  394 
diagnosis  of,  374 

differential,  375 

from  carcinoma,  376 
from  displacement  of 

uterus,  377 
from  floating  kidney, 

379 
from  incomplete  abor- 
tion, 377 
from      inversion       of 

uterus,  377 
from  metritis,  377 
from  the  ovary,  378 
from  pelvic  cysts,  378 
from  pelvic  inflamma- 
tory      infiltrations, 
378 
from         sactosalpinx, 

378 
from  sarcoma,  376 
from  tubal  pregnancy, 
376 
etiology  of,  366 
histogenesis  of,  367 
histology  of,  367 
intraligamentous,  390 
nomenclature  of,  367 
pathology  of,  366 
prognosis  of,  379 

non-operative,  379 
operative,  379 
secondary  changes  of,  367 
calcification,  367 
cystic      degeneration, 

367 
fatty       degeneration, 

367 
malignant       changes, 

369 
mucoid   degeneration, 

367 
septic  infection,  368 


INDEX. 


793 


Myoma  of  uterus,  supravaginal  hystero- 
myomectomy  for,  391 
symptoms  of,  373 
hemorrhage,  373 
pain,  374 

pressure  and  traction,  373 
treatment  of,  380 

non-surgical,  380 
electrolysis,  381 
intra-uterine  styptics, 
381 
tamponade,  381 
manipulations,  380 
medication,  380 
surgical,  381 

palliative,  382 
radical         abdominal 
operations,  386 
vaginal        opera- 
tions, 382 
Myomectomy,   abdominal,   drainage  in, 
388 
in    treatment    of    myoma     of 
uterus,  386 
during  pregnancy,  409 
Myometrium,  202 
Myosalpinx,  269 

Nabothian  glands,  219 
Nails,  sterilization  of,  42 
Neisser,  gonococcus  of,  33.  167 
in  acute  metritis,  208 
Nephrectomy,  299 
Nephritis,  355 

Nerves,  sciatic,  palpation  of,  65 
Neuroma  of  vulva,  364 
Nitze's  cystoscope,  86 
Noeggerath,  latent  gonorrhoea  of,  187 
Nuck,  canal  of,  development  of,  509 
Nymphse.     See  Labia  minora. 

development  of,  510 

malformations  of,  524 

O. 

Oophorectomy,  effect  of,  302 
Oophorosalpingectomy,  291 

Dudley's  operation  for,  292 
Operations,  major,  120 

abdominal  section,  120 

adhesions  in,  124 
closure  of  wound   in, 

126 
dressings    and    band- 
ages in,  134 
incision  in,  122 

exploratory,  122 
median     through 
linea  alba,  122 
intraperitoneal  htemo- 
stasis      in, 
124 
sutures      in, 
125 


Operations,    major,    abdominal   section, 
preparatory     treat- 
ment of,  122 
sponges  in,  129 
Trendelenburg      posi- 
tion in,  120 
substitute  for,  122 
after-treatment  of,  148 

complicated  cases,  150 

fecal    fistula    in, 

157 
hemorrhage      in, 

151 
hysterical  vomit- 
ing, 155 
obstruction        of 
bowels  in,  155 
removal     of     su- 
tures in,  158 
sepsis  in,  153 
general,  154 
locahzed,  153 
shock  in,  150 
stitch-abscess  in, 

158 
ventral  hernia  in, 
158 
simple  cases,  148 

care    of    bladder 
in,  149 
of  bowels  in, 

149 

of  cicatrix  in, 

150 

food  in,  150 

getting-up  in,  150 

hot-water     bags, 

149 
pain  in,  150 
rest,  148 
thirst,  149 
drainage  in,  138 

comparison   of   results   of, 

138 
evil  results  of,  139 

fecal   fistula,    139 
hernia,  139 
iodoform  poison- 
ing, 139 
obstruction        of 

bowel,  139 
vesical  complica- 
tions, 139 
forms  of,  142 

abdominal,  145 
capillary,  142 
postural,  145 
tubular,  142 
vaginal,  146 
peritoneal,    contraindica- 
tions for,  142 
indications  for,  142 
to  prevent  infection,  139 
in  sacral  resection,  137 
in  vaginal  section,  136 
minor,  99 


794 


INDEX. 


Operations,  minor,  anaesthesia  in,  100 
chloroform,  100 
cocaine,  100 
ether,  100 
salt  water,  101 
curettage  in,  115,  117 
dilatation  of  uterus,  109 

diverging  instruments 

in,  112 
forcible,  technique  of, 

115 
graduated  bougies  in, 

112 
incision  in,  110 
Dudley's,  111 
Scliroeder's 
method,  110 
special    advantages 
of     each     method, 
114 
tents  in.  111 
during  pregnancy,  105 
instruments  in,  101 
scissors,  101 
sponge-holders,  103 
uterine  tenaculum,  103 
multiple,  105 
plastic,  106 

after-treatment  of,  109 
assistants  in,  109 
denudation  in,  106 
needles  in,  107 
sutures  in,  application  of, 
107 
removal  of,  109 
union  by  first  intention  in, 
106 
preparatory  treatment  for,  99 
Staffordshire  knot,  118 
tables  for,  99 
Os  uteri,  pinhole,  225 
Ovarian  cysts,  438 

corpus  luteum  cysts,  440 
cyst-adenomata,  441 
papillary,  442 
simple,  441 
dermoid,  444 

complicated,  445 
simple,  444 
diagnosis  of,  456 
adhesions,  458 
differential,  459 

from  ascites,  466 
from  dilated  stomach, 

462 
from   distended  blad- 
der, 462 
from  fat  in  abdominal 

wall,  462 
from  fecal  accumula- 
tions, 462 
from  gestation  in  one 
horn    of   bifurcated 
uterus,  464 
from      haematometra, 
465 


Ovarian  cysts,  diagnosis  of,  differential, 
from  hydatid  cysts, 
467 
from  hydrometra,  465 
from  metritis,  465 
from    normal     gesta- 
tion, 463 
from  phantom  tumor, 

462 
from  physometra,  465 
from  pyometra,  465 
from  renal  tumors,  468 
from  tubal  pregnancy, 

463 
from  tympanites,  462 
from     uterine     carci- 
noma, 464 
sarcoma,  464 
malignancy,  458 
distinction  between  parovarian 

cyst  and,  459 
exploratory  incision  in,  469 
follicular,  439 
formation  of  pedicle  of,  448 
mode  of  development  of,  438 
multilocular,  438 
prognosis  of,  458 
removal  of,  470 

abdominal  incision,  470 
accidents  in,  479 
after-treatment  of,  479 
closure  of  wound  after,  479 
complications  of,  479 
drainage  in,  479 
emptying  and  delivery  of 

cyst,  472 
ligature  of  pedicle,  479 
preparatory  treatment,  470 
secondary  changes  in,  451 
infection,  451 

adhesions,  452 
suppuration,  454 
rupture  of,  453 
causes  of,  454 
diagnosis  of,  454 
prognosis  of,  454 
results  of,  454 
symptoms  of,  454 
treatment  of,  455 
twisting     of     pedicle, 
452 
symptomatology  of,  455 
unilocular,  438 
hydrocele,  450 
pregnancy,  486 

treatment  of,  502 

by  abdomen,  502 
by  vagina,  502 
Ovaries,  absence  of,  511 
accessory,  511 
anatomy  of,  25,  438 
conservative  operation  on,  331 
contraction  of,  761 
cortex  of,  438 
cyst  of,  adenomatous,  441 
intraligamentous,  479 


INDEX. 


795 


Ovaries,  Graafian  follicle  of,  438 

hernia  of,  742 

diagnosis  of,  742 
treatment  of,  742 

malformation  of,  511 

clinical  significance  of,  512 
diagnosis  of,  512 

medullary  zone  of,  438 

microcystic  degeneration  of,  440 

papilloma  of,  443 

removal  of,  for  hsematometra,  535 

sclerosis  of,  761 

senile  changes  in,  29 

supernumerary,  511 

tumors  of,  solid,  436 

diagnosis  of,  436 
treatment  of,  436 

vascular  zone  of,  438 
Ovariotomy,  470 

abdominal  incision  in,  470 

adhesions  in,  478 

appliances  for,  470 

closure  of  wound  in,  479 

delivery  of  cyst  in,  478 

during  pregnancy,  480 

emptying  of  cyst  in.  478 

instruments  for,  470 

ligature  of  pedicle  in,  478 

preparatory  treatment  for,  470 

vaginal,  480 
Ovaritis,  281 

chronic,  dysmenorrhoea  and,  758 

diagnosis  of,  282 
differential,  283 

etiology  of,  281 

pathology  of,  comparative,  281 

physical  signs  of,  282 

symptoms  of,  282 

treatment  of,  283 
Ovula  Nabothi,  219 
Ovulation,  25 
Oxalic  acid  as  an  antiseptic  agent,  35,  41 


P. 

Pachydermia  of  vulva,  358 
Pachyperitonitis,  285 
Papillary  erosions  of  cervix  uteri,  219 
Papilloma  of  ovary,  443 
benign,  436 
of  vulva,  359 

gonorrhoeal,  360 

treatment  of,  361 
non-specific,  360 

treatment  of,  360 
simple,  360 

treatment  of,  360 
syphilitic,  361 
Paradidymis,  development  of,  509 
Parametritis.         See     Pelvic     cellulitis, 

260 
Paravaginal  hysterectomy  in  carcinoma 

of  uterus,  422 
Paravaginitis,  191 
treatment  of,  191 


Paroophoron,  development  of,  508,  509 
Parovarian    cysts,    438,    446.     See   ulao 
Ovarian  cysts, 
contents  of,  448 
distinction     between     ovarian 
cysts  and,  449 
Parovarium,  development  of,  509 
Pathological  amenorrhoea,  23 
Pedicle,  ligature  of,  in  removal  of  ovarian 

cysts,  478 
Pediculi  pubis  in  vulvitis,  180 
Pelvic  cellulitis,  260 

acute  metritis  and,  209 
anatomy  of,  260 
diagnosis  of,  263 

differential,  265 
etiology  of,  260 
pathological  anatomy  of,  201 
pathology  of,  261 
prognosis  of,  266 
symptoms  of,  263 

con.sistence  of,  265 
form  of,  264 
immobility,  265 
location  of,  264 
pain  in,  265 
relations  of,  265 
treatment  of,  266 

non-surgical,  267 
surgical,  266 
cysts  differentiated  from  myoma  of 

uterus,  378 
hfematocele    resulting    from    tubal 

pregnancy,  494 
inflammation,  257 
etiology  of,  258 
routes  of  infection,  257 

by  blood-vessels,  257 
by  continuity  of  nui- 

cosa,  257 
from    extrapelvic    or- 
gans. 257 
by  lymph-vessels,  257 
significance  of,  258 
peritonitis.  283 

de.scription  of,  283 
diagnosis  of.  286 

differential,  286 
pathology  of,  283 
symptoms  of.  285 
treatment  of,  287 

non-surgical.  287 

by  electricity,  289 
general,  287 
by  hot  hip-pack.  289 
local,  288 
by  massage.  289 
medical,  287 
surgical,  291 

by  abdominal  section, 
291 
advantages 

of,  328 
com  plica- 
tions     in, 
294 


796 


INDEX. 


Pelvis  peritonitis,  treatment  of,  surgical, 
by   abdominal   sec- 
tion,    Dudley's 
operation,  299 
by  vaginal  section,  299 
advantages 

of,  329 
anterior,  300 
posterior, 
300 
suppuration,  acute,  vaginal  incision 
and  drainage  for,  326 
Penis,  development  of,  510 
Perilymphangitis.     See  Pelvic  cellulitis. 

acute  metritis  and,  209 
Perimetritis,  tubercular,  327 
Perineal  region,  anatomy  of,  538 

functions  of,  539 
Perineorrhaphy,  549 
complete,  560 

treatment  of,  after-,  564 
preparatory,  562 

denudation,  562 
passing  of  sutures,  563 
direction  of  tear,  549 
mechanism  of,  549 
objects  of,  560 
for  prolapsus  uteri,  556 
technique   of,  for    incomplete    rup- 
ture, 554 
primary        operation, 

554 
secondary    operation, 
554 
treatment  of,  preparatory,  554 
Perineum,  anatomy  of,  538 
functions  of,  539 
lacerations  of,  540 
causes  of,  541 
complete,  541,  544 
incomplete,  543 
prevention  of,  541 
results  of,  542 
Periphlebitis.     See  Pelvic  cellulitis. 

acute  metritis  and,  209 
Perisalpinx,  269 
Peritoneal  drainage,  142 
Peritonitis,  adhesive,  283 

after  abdominal  operations,  154 
exudative,  283 
pelvic,  283 

description  of,  283 
diagnosis  of,  286 

differential,  286 
pathology  of,  283 
symptoms  of,  285 
treatment  of,  287 

non-surgical,  287 
surgical,  291 

by  abdominal  section, 

291 
by  vaginal  section,  299 
plastic,  283 
tubercular,  285 
Pessaries,  adjustment  of,  688 
in  anteflexion  of  uterus,  718 


Pessaries,  Emmet's,  688 
functions  of,  686 
Schultz's,  687 
Smith's,  687,  689 
Thomas',  690 
Phantom  tumors  differentiated  from  ova- 
rian cysts,  462 
Phosphatic  deposits  in  vesicovaginal  fis- 
tula, 597 
Physiological  amenorrhoea,  23 
periods,  21 

infancy,  21 
maturity,  28 
menopause,  29 
puberty,  22 
senility,  31 
Physometra  differentiated  from  ovarian 

cysts,  465 
Pinhole  os  uteri,  224 
Placenta,  formation  of,  in  tubal  preg- 
nancy, 487 
retained,  differentiated  from  carci- 
noma of  uterus,  416 
Plastic  operations,  106 

after-treatment  of,  109 
assistants  in,  109 
denudation  in,  106 
needles  in,  107 
sutures  in,  application  of,  107 

removal  of,  109 
union  by  first  intention  in,  106 
peritonitis,  283 
Pneumococcus,  33 
Polypoid  endocervicitis,  224 

glandular    enlargements    of    cervix 
uteri,  219 
Post-abortum  endometritis,  232 
Potassium   permanganate    as    an    anti- 
septic agent,  35,  41 
Pozzi,  diffuse  cellulitis  of,  261 
Precocious  menstruation,  24 
Pregnancy,  abdominal,  486 

minor  operations  during,  105 
myomectomy  during,  409 
ovarian,  486 

treatment  of,  502 
ovariotomy  during,  480 
tubal,  486 

abortion  in,  490 
course  of,  490 
development  of,  490 
diagnosis  of,  497 
differential,  498 

from  myoma  of  uterus, 

375 
from    ovarian    cysts, 
463 
etiology  of,  486 
formation  of  amnion  in,  487 
of  chorion  in,  487 
of  decidua  in,  487 
of  placenta  in,  487 
frequency  of,  488 
pelvic     haematocele     resulting 

from,  494 
prognosis  of,  499 


INDEX. 


797 


Pregnancy,  tubal,  rupture  in,  491 
secondary  changes  in,  493 
symptoms  of,  493 
treatment  of,  499 

abdominal  versus  vaginal 

route,  502 
after  abortion,  500 

rupture,  500 
before  abortion,  500 

rupture,  500 
if  abortion  has  occurred, 

500 
if  gestation  has  advanced 
beyond   fourth   or    fifth 
month,  501 
if  rupture  has  occurred,  500 
varieties  of,  488 
ampullar,  490 
interstitial,  489 
isthmic,  490 
viability  of  child  at  term,  499 
Prepuce,  adherent,  526 

malformations  of,  524 
Probes,  dangers  of,  76 

passage  of,  75 
Procidentia  uteri.     See  Uterus,  descent 

of. 
Proctoscope  in  examination  of  anus,  78 

of  rectum,  78 
Prolapse  of  urethral  mucosa  complicat- 
ing urethritis,  338 
treatment  of,  339 
Pronephric  ducts,  development  of,  504 
Pronephros,  development  of,  504 

glomeruli  of,  development  of,  505 
Prostate  gland,  development  of,  510 
Protracted  menstruation,  24 
Pruritus  of  vulva,  194 
course  of,  196 
diagnosis  of,  196 
etiology  of,  195 
pathology  of,  195 
prognosis  of,  196 
symptoms  of,  196 
treatment  of,  197 
surgical,  197 
Pryor  on  treatment  of  endometritis,  213 
Puberty,  anatomical  basis  of,  22 
care  during,  26 
education  during,  27 
goitre  of,  28 

physiological  features  of,  23 
Puerperal  atrophic  metritis,  253 
fever,  215 

treatment  of,  215 

metritis,  hypertrophic,  251 

treatment  of,  215 

with  alcohol,  215 

with   antistreptococcic 

serum,  215 
with  argentum  coUoidale, 

215 
with  Crede's  ointment,  215 
with  creolin,  215 
by  gauze  curettage,  215 
by  irrigation,  215 


Purulent  salpingitis,  273 
Pyaemia,  33 

in  acute  metritis,  212 
Pyelitis,  355 
Pyocolpos,  530 
Pyometra,  530 

differentiated  from   ovarian   cysts, 
465 
Pyosalpinx,  271,  530 
Pyo-ureter,  355 

R. 

Radical    abdominal    hysterectomy    in 

carcinoma  of  uterus,  423 
Rectal  examination,  conjoined,  62 
Rectocele,  544 

in  lacerations  of  perineum,  54 
Rectovaginal    examination,    conjoined, 
64 
fistula,  635 

causes  of,  635 
diagnosis  of,  635 
prognosis  of,  635 
treatment  of,  635 
Rectum,  examination  of,  78 
proctoscope  in,  78 
sigmoidoscope  in,  78 
Reid's  drainage-tube,  143 
Renal  tumors  differentiated    from    ova- 
rian cysts,  468 
Retroflexion  of  uterus,  671 
congenital,  709 
course  of,  672 
diagnosis  of,  673 

of  complications,  673 
differential,  674 
in  perineum,  673 
etiology  of,  671 
pathology  of,  671 
symptoms  of,  672 
treatment  of,  675 

intra-abdominal     shorten- 
ing of  round  ligaments 
in,  700 
method     of    replacement, 

676 
obstacle    to    replacement, 

675 
replacement  and  retention 
of  retroposed  uterus,  670 
retention  by  pessaries,  684 
surgical,  087 

abdominal     hysteror- 

rhaphy  in,  702 
Alexander's        opera- 
tion, 691 
shortening    of    utero- 
sacral  ligaments  in, 
702 
vaginal     hysterorrha- 
phy in,  708 
Retrolocation  of  uterus,  636 
diagnosis  of,  636 
symptoms  of,  636 
treatment  of,  036 


^98 


INDEX. 


Retroversion  of  uterus,  668 
congenital,  709 
course  of,  669 
degrees  of,  670 
description  of,  668 
diagnosis  of,  670 
etiology  of,  668 
prognosis  of,  670 
symptoms  of,  669 
treatment  of,  671,  675 

method    of    replacement, 

676 
obstacles  to   replacement, 

675 
retention  by  pessaries,  684 
surgical,  687 

abdominal     hysteror- 

rhaphy  in,  702 
Alexander's        opera- 
tion, 691 
intra-abdominal 
shortening  of  round 
ligaments  in,  700 
shortening    of    utero- 
sacral  ligaments  in, 
702 
vaginal    hysterorrha- 
phy,  708 
Reynolds  on  Dudley's  operation  for  ante- 
flexion of  uterus,  726 
Ries  on  radical  abdominal  hysterectomy, 

423 
Rosenmueller,  organ  of,  development  of, 

509 
Round  ligament,  intra-abdominal  short- 
ening of,  in  Alexander's  ope- 
ration, 700 
tumors  of,  482 
Rubber  gloves,  42 
Rudimentary  development  of  tubes,  513 

ovaries,  512 
Rumpf  on  radical  abdominal  hysterec- 
tomy, 423 
Rupture  in  tubal  pregnancy,  491 
Russell  on  radical  abdominal  hysterec- 
tomy, 423 

S. 

Sacral  resection,  137 
Sactosalpinx,  271 

chronic,  vaginal  incision  and  drain- 
age for,  325 

differentiated  from  myoma  of  uterus, 
378 

hsemorrhagica,  271 

purulenta,  271 

serosa,  271 
Salpingitis,  268 

catarrhal,  273 

chronic,  dysmenorrhoea  and,  758 

classification  of,  269 

diagnosis  of,  275 

differential,  278 

etiolo^  of,  269 

normal  anatomy  of,  268 


Salpingitis,  pathology  of,  270 
profluens,  761 
prognosis  of,  280 
purulent,  273 
symptoms  of,  274 

comparative,  275 
mechanical  disturbances,  275 
menstrual  disturbances,  275 
pain,  274 
treatment  of,  281 
surgical,  305 
tubercular,  276 

diagnosis  of,  277 
Salpingo-stomatomie,  330 
Salt  water  infusion,  153 
Saprsemia,  32 

in  acute  metritis,  211 
Sarcoma  differentiated  from  myoma  of 
uterus,  376 
of  endometrium,  237 
of  Fallopian  tubes,  482 
of  ovary,  436 
of  round  ligament,  483 
of  urethra,  484 
of  uterus,  431 

classification  of,  431 
course  of,  432 
diagnosis  of,  432 
differentiated  from  carcinoma, 
417 
from  ovarian  cysts,  464 
etiology  of,  431 
histogenesis  of,  431 
pathological  anatomy  of,  431 
prognosis  of,  432 
spindle-cell,  432 
symptoms  of,  432 
treatment  of,  433 
of  vagina,  365 

treatment  of,  365 
of  vulva,  362 

treatment  of,  363 
Sarcomatous  degeneration  of  uterus,  432 
Scanty  menstruation,  24 
Schauta  on  paravaginal   hysterectomy, 
423 
on  radical  abdominal  hysterectomy, 
423 
Schleich's  solution  of  cocaine,  100 
Schroeder's    incision    in    dilatation     of 
uterus,  110 
operation  for  chronic  endocervicitis, 
222 
Schuchardt's  operation,  422 
Schultz  pessary,  687 
Sciatic  nerves,  palpation  of,  65 
Sclerosis  of  ovary,  761 
Scrotum,  development  of,  510 
Senile  endometritis,  232 
vulvovaginitis,  186 
Senihty,  31 

Sepsis  after  abdominal  operations,  153 
general,  154 

treatment  of,  154 
localized,  153 
Septic  infection,  32 


INDEX. 


799 


Septicaemia,  32 

in  acute  metritis,  211 
Sex,  differentiation  of,  510 
Sigmoidoscope  in  examination  of  anus, 
78 
of  rectum,  78 
Silkworm  gut,  sterilization  of,  43 
Simon's  speculum,  73 

use  of,  73 
Simpson's  sound,  75 
Sims'  glass  vaginal  plug,  600 
position,  70 
correct,  70 
incorrect,  71 
sigmoid  catheter,  608 
sound,  75 
speculum,  69 

self-retaining,  70 
use  of,  71 
Sinuses,  prevention  of,  157 
Skene's  glands,  anatomy  of,  333 

inflammation  of,  334 
Smith's  pessary,  687,  689 
Soap  as  an  antiseptic  agent,  35 
Sodium  carbonate  as  an  antiseptic  agent, 

35 
Sounds,  dangers  of,  76 
passage  of,  75 
Simpson's,  75 
Sims',  75 
Speculum,  Simon's,  73 
use  of,  73 
Sims',  69 

self-retaining,  70 
use  of,  71 
Sphincter,  rigid,  in  vulvovaginitis,  178 
Sponges,  sterilization  of,  43 
Staffordshire  knot,  118 
Stapler,  cellulitis  of,  263 
Staphylococcus,  33 

in  acute  metritis,  208 
Sterility,  763 

acquired,  767 

causes  of,  congenital,  766 

indeterminate,  769 
classification  of,  763 
absolute,  764 
complete,  764 
partial,  764 
relative,  764 
definition  of,  763 
diagnosis  of,  770 
due  to  anteflexion  of  uterus,  716 
etiology  of,  764 
prognosis  of,  770 
statistics  of,  763 
treatment  of,  770 
SteriUzation,  42 
of  beard,  42 
by  boiling,  35 
of  catgut,  43 

by  chromic  acid  process,  44 
by  dry  heat  process,  44 
of  dressings,  43 
of  field  of  operation,  46 
of  gauze,  45 


Sterilization  of  hair,  42 
of  instruments,  42 
of  nails,  42 

of  patient  for  abdominal  section,  45 
of  sea  sponges,  43 
of  silkworm  gut,  43 
of  sponges,  43 
by  steam,  35 
of  towels,  43 
of  water,  43 
Sterilizers,  37 

Dudley's,  38 
hospital,  37 
steam,  37 
Stomach,    dilated,    differentiated    from 

ovarian  cysts,  462 
Streptococcus  in  acute  metritis,  208 

pyogenes,  33 
Streptothrix  actinomyces,  33 
Submucous  myoma  of  uterus,  370 
Subperitoneal  myoma  of  uterus,  372 
Suburethral    abscess    complicating   me- 
tritis, 338 
treatment  of,  339 
Sulphuric  ether  as  an  antiseptic  agent, 

35 
Supernumerary  tubes,  513 
Supravaginal    hysteromyomectomy    for 
myoma  of  uterus,  391 
disfection  of  vagina  in,  391 
Sutures  in  plastic  operations,   applica- 
tion of,  107 
removal  of,  109 
removal  of,  after  abdominal  opera- 
tions, 158 
Syphilis   of   uterus,   differentiated  from 

carcinoma,  417 
Sypliilitic  vulvovaginitis,  185 

T. 

Tamponade,  94 

indications  for,  94 
hemorrhage,  96 
inflammation,  94 
Tate's  method  of  treatment  in  inversion 

of  uterus,  739 
Tents  in  dilatation  of  uterus.  111 
Teratomata  of  ovary,  445 
Thomas'  pessary,  690 
Topical  applications,  96 

to  endometrium,  96 

selection  of  cases,  96 
technique  of,  98 
Torsion  of  uterus,  727 
causes  of,  727 
diagnosis  of,  728 
treatment  of,  729 
Towels,  sterilization  of,  43 
Toxaemia,  32 

Trachelorrhaphy  for  lacerations  of  cer- 
vix, 579 
after-treatment  of,  592 
approximation  in,  583 
curettage  in,  581 
denudation  in,  583 


800 


INDEX. 


Trachelorrhaphy  for  lacerations  of  cer- 
vix, disinfection  in,  581 
hemorrhage  in,  585 
immediate    operation    in, 

580 
instruments  for,  581 
preliminary  dilatation    in, 

582 
preparatory  treatment  of, 

580 
removal  of  cicatricial  plug 

in,  584 
results  of,  592 
secondary     operation     in, 

580 
sutures  in,  585 
Transversus  perinei  muscle,  543 
Treatment  of  acute  metritis,  211 
of  adenocarcinoma  of  vulva,  362 
of  amenorrhoea,  748 
of  anteflexion  of  uterus,  717 
of  antelocation  of  uterus,  636 
of  anteversion  of  uterus,  711 
of  ascent  of  uterus,  636 
Bier's  cupping,  98 
of  carcinoma  of  uterus,  420 
of  vagina,  365 
of  vulva,  362 
of  chancroidal  vulvovaginitis,  186 
of  chorio-epithelioma  of  uterus,  435 
of  chronic  endocervicitis,  221 
endometritis,  238 
metritis,  256 
of  congenital  gynatresia,  534 
of  cystitis,  348 
of  cysts  of  round  ligaments,  482 

of  vagina,  364 
of  deciduoma  malignum,  435 
of  descent  of  uterus,  647 
of  diphtheritic  vulvovaginitis,  183 
of  dysmenorrhoea,  760 
of  eczema  of  vulva,  192 
of  emphysematous  vaginitis,  191 
of  endometritis,  214 
of  epithelioma  of  uterus,  430 
of  erysipelatous  vulvovaginitis,  183 
of  fibroma  of  round  ligament,  482 
of  fibromyoma  of  vulva,  363 
of  furuncular  vulvitis,  190 
of  glandular  vulvovaginitis,  187 
of  gonorrhoeal  papilloma  of  vulva, 
361 
\'ulvovaginitis,  181 
of  hemorrhage  in  major  operations, 

151 
of  hermaphrodism,  528 
of  hernia  of  ovary,  742 

of  uterus,  742 
of  hydrocele  of  round  ligament,  482 
of  hyperaesthesia  of  vulva,  200 
of  hysterical  vomiting  after  abdomi- 
nal operations,  155 
of  incontinence  of  urine,  772 
of  injuries  of  vulva,  537 
of  inversion  of  uterus,  735,  736 
of  kraurosis  of  vulva,  194 


Treatment  of  lacerations  of  cervix,  579 
of  lateral  location  of  uterus,  636 
of  lipoma  of  vulva,  363 
local,  by  tamponade,  94 

by  topical  application,  96 

by  vaginal  douche,  91 
of  mycotic  vulvovaginitis,  185 
of  myoma  of  round  ligament,  482 

of  uterus,  380 
of  non-specific  papilloma  of  vulva, 

360 
of     obstruction     of     bowels     after 

abdominal  operations,  156 
operative,  of  hypospadias,  523 
of  ovarian  pregnancy,  502 
of  ovaritis,  283 
of  paravaginitis,  191 
of  pelvic  cellulitis,  266 

peritonitis,  287 
of  premature  menstruation,  744 
preparatory,  of  abdominal  section, 
122 

for  minor  operations,  99 
of  prolapse  of  urethral  mucosa,  339 
of  pruritus  of  vulva,  197 
of  puerperal  fever,  215 

metritis,  215 
of  rectovaginal  fistula,  625 
of  retroflexion  of  uterus,  675 
of  retrolocations  of  uterus,  636 
of  retroversion  of  uterus,  671,  675 
of  salpingitis,  281 

surgical,  305 
of  sarcoma  of  uterus,  433 

of  vagina,  365 

of  vulva,  363 
of  sepsis  after  abdominal  operations, 

154 
of  simple  papilloma  of  \ailva,  360 
of  solid  tumors  of  ovary,  436 
of  sterility,  770 
of  suburethral  abscess,  339 
of  torsion  of  uterus,  728 
of  tubal  pregnancy,  499 
of  tuberculous  vulvovaginitis,  184 
of  ureterovaginal  fistula,  618 
of  urethral  caruncle,  484 
of  urethritis,  334 
of  uterine  hemorrhage,  754 
of  vaginismus,  201 
of  varix  of  vulva,  357 
of  vesico-uterine  fistula,  617 
of  vesicovaginal  fistula,  596,  597 
of  vulvitis,  180 
of  vulvovaginitis,  179 
Trendelenburg's  position  in   abdominal 
section,  120 
substitute  for,  122 
Tubal  pregnancy,  486 

abortion  in,  490 

course  of,  490 

development  of,  490 

diagnosis  of,  497 
differential,  498 

from     myoma     of 
uterus,  376 


INDEX. 


801 


Tubal    pregnancy,    diagnosis    of,   differ- 
ential,   from    ovarian    cysts, 
463 
etiology  of,  486 
formation  of  amnion  in,  487 
of  chorion  in,  487 
of  decidua  in,  487 
of  placenta  in,  487 
frequency  of,  488 
pelvic     hsematocele     resulting 

from,  494 
prognosis  of,  499 
rupture  in,  491 
secondary  changes  in,  493 
symptoms  of,  493 
treatment  of,  499 

abdominal   versus   vaginal 

route,  502 
after  abortion,  500 

rupture,  500 
before  abortion,  500 

rupture,  500 
if  abortion   has  occurred, 

500 
if  gestation  has  advanced 
beyond   fourth    or   fifth 
month,  501 
if   rupture    has    occurred, 
500 
varieties  of,  488 
ampullar,  490 
interstitial,  489 
istlmiic,  490 
viability  of  cliild  at  term,  499 
Tubercular  endometritis,  233 
perimetritis,  327 
peritonitis,  285 
salpingitis,  276 

diagnosis  of,  277 
suppuration,    vaginal   incision   and 
drainage  for,  326 
Tuberculosis    of    uterus,    differentiated 
from  carcinoma,  418 
of  vulva,  363 
Tuberculous  vulvovaginitis,  183 

treatment  of,  184 
Tubo-ovarian  cysts,  450 
Tubular  drainage,  142 
Tumors  of  bladder,  485 

of  broad  ligament,  482 
of  Fallopian  tubes,  481 
phantom,  differentiated  from  ova- 
rian cysts,  462 
renal,    differentiated   from   ovarian 

cysts,  458 
of  round  ligament,  482 
solid,  of  ovary,  436 

diagnosis  of,  436 
treatment  of,  437 
of  urethra,  483 
of  uterus,  366 
of  vagina,  357 
of  vulva,  357 
Tympanites,  differentiated  from  ovarian 
cysts,  462 


u. 

Ulceration  of  cervix  and  chronic  endo- 

cervicitis,  221 
Ulcerative  cystitis,  345 
Unilocular  ovarian  cysts,  438 
Ureter,  fistula  to  external  surface  of,  299 
injury  of,  in  abdominal  section,  298 
insertion  of,  into  bladder,  299 
lateral  anastomosis  of,  299 
repair  of,  in  abdominal  section,  298 
suture  of,  in  abdominal  section,  299 
wounds  of,  298 
Ureters,  catheterization  of,  84 
Ureterorrhaphy,  298 
Ureterovaginal  fistula,  618 
causes  of,  618 
diagnosis  of,  618 
treatment  of,  618 

Dudley   clamp   operation, 
619 
Urethra,  atresia  of,  521 
caruncle  of,  334 
development  of,  510 
dilatation  of,  in  treatment  of  cys- 
titis, 352 
reconstruction  of,  523 
tumors  of,  483 
Urethral  caruncle,  483 

diagnosis  of,  484 

differential,  484 
etiology  of,  483 
pathology  of,  483 
treatment  of,  484 
cysts,  187 
irritation     due    to     anteflexion    of 

uterus,  714 
mucosa,   prolapse  of,   complicating 
urethritis,  338 
treatment  of,  339 
Urethritis,  333 

complicated  by  prolapse  of  urethral 
mucosa,  338 
treatment  of,  339 
by  suburethral  abscess,  339 
treatment  of,  339 
diagnosis  of,  333 
etiology  of,  333 
gonorrhoeal,  333 
pathology  of,  333 
treatment  of,  334 
Urethrovaginal  fistula,  618 
Urinary  organs,  examination  of,  78 
catheterization  in,  80 
cystoscopy  in,  SO 

comparison  of,  86 
cylindrical,  80 
electrical,  85 
value  of,  86 
dorsal  position  in,  81 
inspection  in,  78 
knee-breast  position  in,  83 
palpation  in,  78 
percussion  in,  78 
segregation  in,  89 
urethral  exploration  in,  80 


802 


INDEX. 


Urinary   organs,    examination    of,    ure- 
throscopy in,  80 
urinalysis  in,  78 
Urine,  incontinence  of,  771 
treatment  of,  772 
surgical,  776 
Urogenital  sinus,  development  of,  508 
Uterine   appendages,    inflammation    of, 
268 
removal  of,  294 

complications  of,  294 
effect  of,  302 
technique  of,  294 

in  abdominal   hyster- 
ectomy, 297 
in  adhesions,  296 
in  hemorrhage,  297 
in  intestinal  opening, 

297 
in  pus  cases,  294 
in    urethral    wound;;, 
298 
dilators,  77 

discharge  in  carcinoma,  413 
glands,  invagination  of,  226 
hemorrhage,  750 

diagnosis  of,  753 
during  maturity,  754 
menopause,  754 
etiology  of,  750 
of  girls,  753 
treatment  of,  754 

electrotherapeutic,  755 
local,  755 
surgical,  755 
systemic,  754 
inflammation  a  cause  of  hemorrhage, 

750 
moles  a  cause  of  hemorrhage,  752 
tumors  a  cause  of  hemorrhage,  751 
examination  of,  67 
Uterosacral  ligaments,  shortening  of,  in 
retroflexion    of    uterus, 
702 
in  retro-s^ersion  of  uterus, 
702 
Uterus,  anatomy  of,  22,  202 
blood-vessels  of,  203 
endometrium,  202 
glands  of,  202 
lymphatics  of,  204 
lymph-vessels  of,  203 
minute,  202 
nerves  of,  203 
anteflexion,  712 
acquired,  713 
classification  of,  713 
complications  of,  714 
congenital,  713 
course  of,  714 
developmental,  713 
diagnosis  of,  716 
etiology  of,  713 
normal,  712 
pathological,  712 
pathology  of,  713 


Uterus,  anteflexion,  symptoms  of,  714 
urethral,  714 
uterine,  715 

dysmenorrhoea,  716 
endometritis,  715 
_  sterihty,  716 
vesical,  714 
treatment  of,  717 

of  complications,  717 

by  division  of  cervix  uteri, 

723 
by  Dudley's  operation,  723 
by  electricity,  719 
by  forcible  dilatation,  719 
by  local  massage,  719 
mechanical  indications  for, 

718 
by  pessaries,  718 
by  suppositories  of  opium, 
720 
antelocation  of,  636 
diagnosis  of,  636 
symptoms  of,  636 
treatment  of,  636 
anteversion  of,  710 
acquired,  713 
congenital,  710 
diagnosis  of,  711 
etiology  of,  710 
prognosis  of,  711 
symptoms  of,  710 
treatment  of,  711 
ascent  of,  635 

diagnosis  of,  636 
symptoms  of,  636 
treatment  of,  636 
bifurcated,  gestation  in  one  horn  of, 
differentiated  from  ovarian  cysts, 
464 
carcinoma  of,  411 

adenocarcinoma,  411 
cause  of  death  from,  419 
course  of,  412 
cylindrical  cell,  411 
diagnosis  of,  414 

differential,  416 

from  chronic  metritis, 

417 
from      endocervicitis, 

417 
from  endometritis,  417 
froni   hypertrophy   of 

cervix,  417 
from  ichthyosis  uteri, 

417 
from  incomplete  abor- 
tion, 417 
from  laceration  of  cer- 
vix, 418 
from  myoma,  416 
from     ovarian    cysts, 

464 
from     retained     pla- 
centa, 416 
from  sarcoma,  417 
from  syphilis,  417 


INDEX. 


803 


Uterus,  carcinoma  of,  diagnosis  of,  dif- 
ferential, from  tubercu- 
losis, 418 
recurrence  after  removal, 
419 
etiology  of,  412 
extension  of,  411 

diagnosis  of,  419 
gland,  411 
pathology  of,  411 
pavement-cell,  411 
prognosis  of,  419 
symptoms  of,  412 
cachexia,  414 
hemorrhage,  413 
pain,  413 

uterine  discharge,  413 
visceral  disorders,  413 
treatment  of,  420 

hysterectomy  in,  421 

ignihysterectomy, 

425 
mortality      from, 

428 
paravaginal,  422 
radical       abdom- 
inal, 423 
recurrence    after, 
428 
operation    of    election   in, 

428  _ 
palliative,  429 
descent  of,  637 
course  of,  645 
diagnosis  of,  645 

differential,  645 
etiology  and  mechanism  of,  637 
pathology  of,  643 
prophylaxis  of,  646 
treatment  of,  647 

change     in     direction     of 

vagina  in,  650 
elytrorrhaphy  in,  651 
general,  647 
hygiene  in,  647 
hysterectomy  in,  650 
hysterorrhaphy  in,  666 
local,  647 
narrowing    of    vagina    in, 

650 
perineorrhaphy  in,  655 
by  pessaries,  648 
by  plastic  operations,  650 
de\'elopment  of,  507 
dilatation  of,  77,  109 

diverging  instruments  in,  112 
forcible,  technique  of,  115 
by  graduated  bougies,  77,   112 
incision  in,  110 
Dudley's,  111 
Schroeder's  method,  110 
special     advantages     of     each 

method,  114 
by  steel  instruments,  77 
by  tents,  77,  HI 
by  water  dilators,  77 


Uterus,  displacements  of,  627 
definition  of,  631 
diagnosis  of,  631 

from  myoma,  377 
general  considerations  of,  627 
nomenclature  of,  631 
symptoms  of,  631 
endothelioma  of,  430 
diagnosis  of,  430 
pathology  of,  430 
treatment  of,  430 
flexion  of,  709 
foreign  bodies  in,  hemorrhage  from, 

752 
hernia  of,  640,  742 
diagnosis  of,  742 
treatment  of,  742 
ichthyosis    of,    differentiated    from 

carcinoma,  417 
infantile,  22 

inflammation  of.    See  Metritis, 
inversion  of,  729 

anatomy  of,  732 
diagnosis  of,  733 

from  myoma,  377 
etiology  of,  729 
mechanism  of,  732 
pathology  of,  732 
prognosis  of,  735 
symptoms  of,  733 
treatment  of,  acute,  735 
chronic,  736 

by  colpeurynter,   739 
by     elastic     pressure, 

739 
by  hysterectomy,  742 
by  incision,  741 

Brown's  methoil, 
741 
manual,  738 

Emmet's  method, 

738 
Tate's      method, 
739 
preparatory,  737 
by  spiral  spray,  741 
White's    method, 
741 
by  water  bag,  739 
varieties  of,  735 
lateral  location  of,  636 

diagnosis  of,  636 
symptoms  of,  636 
treatment  of,  636 
malformations  of,  513 
masculinus.  development  of,  510 
myoma  of,  366 

classification  of,  369 
cervical.  372 
intramural,  369 
submucous.  370 
subperitoneal,  372 
complete    abdominal    hystero- 

myomectomy  for,  394 
diagnosis  of,  374 

differential,  375 


804 


INDEX. 


Uterus,  myoma  of,  diagnosis  of,  differ- 
ential,   from    carci- 
noma, 376 
from  displacement  of 

uterus,  377 
from  floating  kidney, 

379 
from  incomplete  abor- 
tion, 377 
from      inversion      of 

uterus,  377 
from  metritis,  377 
from  the  ovary,  378 
from  pelvic  cysts,  378 
inflammatory  in- 
filtrations, 378 
from  sactosalpinx,  378 
from  sarcoma,  376 
from  tubal  pregnancy, 
376 
etiology  of,  366 
histogenesis  of,  367 
histology  of,  367 
intraligamentous,  390 
nomenclature  of,  367 
pathology  of,  366 
prognosis  of,  379 

non-operative,  379 
operative,  379 
secondary  changes  of,  367 
calcification,  367 
cystic      degeneration, 

367 
fatty       degeneration, 

367 
malignant       changes, 

369 
mucoid  degeneration, 

367  _ 
septic  infection,  368 
supravaginal    hysteromyomec- 

tomy  for,  391 
symptoms  of,  373 
hemorrhage,  373 
pain,  374 

pressure  and  traction,  373 
treatment  of,  380 

non-surgical,  380 
electrolysis,  381 
intra-uterine  styptics, 
381 
tamponade,  381 
manipulations,  380 
medication,  380 
surgical,  381 

palliative    operations, 

382 
radical  abdominal  op- 
erations, 386 
vaginal        opera- 
tions, 382 
normal  movements  of,  629 
position  of,  628 
supports  of,  629 
prolapse  of.     See  Uterus,  descent  of. 
retroflexion  of,  671 


Uterus,  retroflexion  of,  congenital,  709 
course  of,  672 
diagnosis  of,  673 

of  complications,  673 
differential,  674 
in  perineum,  673 
etiology  of,  671 
pathology  of,  671 
symptoms  of,  672 
treatment  of,  675 

method     of     replacement, 

676 
obstacles  to   replacement, 

675 
replacement  and  retention 
of  retroposed  uterus,  679 
retention  by  pessaries,  684 
surgical,  691 

abdominal     hysteror- 

rhaphy  in,  702 

technique  of,  706 

Alexander's  operation, 

691 
intra-abdominal 
shortening  of  round 
ligaments  in,  700 
shortening    of    utero- 
sacral  ligaments  in, 
702 
vaginal     hysterorrha- 
phy  in,  708 
retrolocation  of,  636 
diagnosis  of,  636 
symptoms  of,  636 
treatment  of,  636 
retroversion  of,  668 
congenital,  709 
course  of,  669 
degrees  of,  670 
description  of,  668 
diagnosis  of,  670 
etiology  of,  668 
prognosis  of,  670 
symptoms  of,  669 
treatment  of,  671,  675 

method     of    replacement, 

676 
obstacles  to  replacement, 

675 
replacement  and  retention 
of  retroposed  uterus,  679 
retention  by  pessaries,  684 
surgical,  691 

abdominal     hysteror- 

rhaphy  in,  702 
Alexander's  operation, 

691 
intra-abdominal 
shortening  of  round 
ligaments  in,  700 
shortening    of    utero- 
sacral  ligaments  in, 
702 
vaginal     hysterorrha- 
phy  in,  708 
sarcoma  of,  431 


INDEX. 


805 


Uterus,  sarcoma  of,  classification  of,  431 

course  of,  432 

diagnosis  of,  432 

differentiated  from  carcinoma, 
417 
from  ovarian  cysts,  464 

etiology  of,  431 

histogenesis  of,  431 

pathological  anatomy  of,  431 

prognosis  of,  432 

spindle-cell,  432 

symptoms  of,  432 

treatment  of,  433 
sarcomatous  degeneration  of,  432 
senile  changes  in,  29 
septus,  516 

syphilis  of,  differentiated  from  carci- 
noma, 417 
torsion  of,  727 

causes  of,  727 

diagnosis  of,  728 

treatment  of,  728 
tuberculosis  of,  differentiated  from 

carcinoma,  418 
tumors  of,  366 
unicornis,  518 

ventrovaginal  reposition  of,  679 
version  of,  709 

V. 

Vagina,  artificial,  for  hsematometra,  535 
aspiration  of  hydrosalpinx  through, 

324 
atresia  of,  521 
carcinoma  of,  365 

treatment  of,  365 
changes  in  direction  of,  in  descent  of 

uterus,  650 
complete  absence  of,  519 
cysts  of,  364 

treatment  of,  364 
fibromyoma  of,  365 
inflammatory  atresia  of,  519 
injuries  of,  527 
malformations  of,  518 
narrowing,  in  descent  of  uterus,  650 
sarcoma  of,  365 

treatment  of,  365 
septa,  518 

topical  applications  to,  98 
tumors  of,  357 
Vaginal  cystotomy  in  treatment  of  cys- 
titis, 352 
drainage,  146 
enucleation  in  treatment  of  myoma 

of  uterus,  383 
hysterectomy     in      treatment      of 
myoma  of  uterus,  383 
of  pelvic  inflammation,  304 
hysterorrhaphy,  708 

technique  of,  708 
incision  and  drainage  for  acute  pel- 
vic suppuration,  326 
for   chronic    sactosalpinx, 
325 
49 


Vaginal  incision  and  drainage  as  a  tem- 
porizing measure,  328 
for  tubercular  suppuration, 
326 
morcellation  in  treatment  of  myoma 

of  uterus,  383 
operations,  aseptic,  preparation  for, 

48 
ovariotomy,  480 
section,  136 

in  treatment  of  pelvic  inflam- 
mations, 299 
Vaginismus,  200 
course  of,  200 
etiology  of,  200 
treatment  of,  201 
Vaginitis.     See  Vulvovaginitis, 
dissecting,  191 
emphysematous,  190 

treatment  of,  191 
gonorrhoeal,  in  cliildren,  181 
lactic  acid  bacteria  in,  78 
superficial,  186 
Van  Hook  on  repair  of  ureter,  298 
Varix  of  vulva,  357 

treatment  of,  357 
Vas  deferens,  development  of,  509 
Ventral  hernia  after  abdominal  opera- 
tions, 158 
Ventro-rectovaginal  reposition  of  uterus, 

683 
Ventro-vaginal  reposition  of  uterus,  679 
Version  of  uterus,  709 
Vesical   complications   from   abdominal 
drainage,  139 
irritation  due  to  anteflexion,  714 
Vesico-uterine  fistula,  617 
diagnosis  of,  617 
treatment  of,  617 
Vesico-uterovaginal  fistula,  593,  594 
Vesicovaginal  fistula,  594 

cause  of  cystitis,  595 
course  of,  595 
diagnosis  of,  595 
etiology  of,  594 
prognosis  of,  595 
symptoms  of,  595 
treatment  of,  prophylactic,  596 
surgical,  597 

atypical      operations, 

609 
operations  for  closing, 

601 
preparatory,    597 
Virchow,  erysipelas  malignum  internum 

of,  261 
Visceral    diseases    a   cause    of    uterine 

hemorrhage,  752 
Vomiting,    hysterical,    after    abdominal 

operations,  155 
von  Rosthom  on  radical  abdominal  hys- 
terectomy, 423 
Vulva,  adenocarcinoma  of,  361 
diagnosis  of,  361 
treatment  of,  362 
carcinoma  of,  361 


806 


INDEX. 


Vulva,  carcinoma  of,  cylindrical-cell,  361 
treatment  of,  362 

pavement-cell,  361 
diagnosis  of,  361 
cysts  of,  363 
eczema  of,  192 

treatment  of,  192 
elephantiasis  of,  358 

diagnosis  of,  differential,  358 
enchondroma  of,  364 
fibromyoma  of,  363 

treatment  of,  363 
hsematoma  oi,  358 
herpes  of,  192 
hyperaesthesia  of,  199 

treatment  of,  200 
injuries  of,  537 

etiology  of,  537 

symptoms  of,  537 

treatment  of,  537 
kraurosis  of,  193 

pathology  of,  193 

treatment  of,  194 

Longyear's  operation,  194 
lipoma  of,  363 

treatment  of,  363 
lupus  of,  183,  363 
malformations  of,  520 
neuroma  of,  364 
pachydermia  of,  358 
papilloma  of,  359 

gonorrhoeal,  360 

treatment  of,  361 

non-specific,  360 

treatment  of,  360 

simple,  360 

treatment  of,  360 

syphilitic,  361 
pruritus  of,  194 

course  of,  196 

diagnosis  of,  196 

etiology  of,  195 

pathology  of,  195 

prognosis  of,  196 

symptoms  of,  196 

treatment  of,  197 
sarcoma  of,  362 

treatment  of,  363 
topical  applications  to,  98 
tuberculosis  of,  363 
tumors  of,  357 
varix  of,  357 

treatment  of,  357 
vestibule  of,  development  of,  510 
Vulvitis.      See  also  Vulvovaginitis, 
buboes  in,  180 
foUicular,  189 

treatment  of,  190 
furuncular,  190 

treatment  of,  190 
glandular,  187 

diagnosis  of,  187 

treatment  of,  187 
pediculi  pubis  in,  180 
superficial,  186 
treatment  of,  180 


Vulvovaginal  abscess,  187 

glands,  inflammation  of,  187 
Vulvovaginitis,  174 
chancroidal,  186 

treatment  of,  186 
in  children,  180 
chronic,  179 
classification  of,  174 

anatomical,  175 

etiological,  174 
definition  of,  174 
diagnosis  of,  178 
diphtheritic,  183 

treatment  of,  183 
epidemics  of,  176 
erysipelatous,  182 

erythematous,  182 

gangrenous,  182 

treatment  of,  183 

vesicular,  182 
etiology  of,  175 

exciting  causes,  175 

favoring  conditions,  175 
foUicular,  189 
glandular,  187 

diagnosis  of,  187 

treatment  of,  187 
gonorrhoeal,  181 

diagnosis  of,  181 

treatment  of,  181 
mycotic,  184 

diagnosis  of,  184 

etiology  of,  184 

prognosis  of,  184 

symptoms  of,  184 

treatment  of,  185 
pathology  of,  176 
senile,  186 
symptoms  of,  178 
syphilitic,  185 
treatment  of,  179 
tuberculous,  183 

treatment  of,  184 

W. 

Wadsworth  on  Dudley's  operation  for 

anteflexion  of  uterus,  726 
Waist  constriction,  160 
Waldeyer,  yellow  body  of,  development 

of,  509 
Warts  of  urethra,  484 

of  vulva.     See  Papilloma  of  vulva. 
Water,  sterilization  of,  42 
Werder  on  ignihysterectomy,  425 

on  radical  abdominal  hysterectomy, 
423 
Werth  on  regeneration  of  epithelium,  248 
Wertheim  on  radical  abdominal  hyster- 
ectomy, 424 
White's  method  of  treatment  in  inver- 
sion of  uterus,  741 
Wolffian  body,  development  of,  504 

ducts,  development  of,  504 

ridge,  development  of,  503 
Wounds  of  ureter,  298 


RGlOl 


i~v y-\ 


D86 
1908 


>..!r:i 


IS 


m 


^m^ 


^# 

Utm 

lit 

(^ 


i# 


